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Health Screening Questionnaire

Please read and answer the following questions by selecting Yes or No as appropriate. 

If you opt not to complete this screen, or answer Yes to ANY of the below questions, please be aware it is our corporate policy that you may not enter the building.

If you are an employee, please contact management to review.

If you are a customer or vendor, please know we would love to see you but ask that you please contact us via phone or email at this time for any assistance needed.

Thank you.

Health Screening Form
Have you had a fever greater than 100F / 37.8C within the last 24 hours? *
Do you have a severe cough that started or has gotten worse in the last 48 hours? *
Do you have shortness of breath that started in the last 48 hours? *
Do you have muscle aches that started or have gotten worse in the last 48 hours? *
In the last 48 hours, have you felt significantly more tired than usual? *
Do you have a sore throat that has started or gotten worse in the last 48 hours? *
In the last 48 hours, have you had new loss of taste or smell? *
Are you waiting on results of a COVID-19 test? *
In the past 14 days, have you been exposed to someone with known or suspected COVID-19? *
Symptoms of COVID-19 include fever chills, shortness of breath, muscle aches, fatigue, runny nose, nasal congestion, sore throat, nausea, diarrhea and loss of taste or smell.
Signature *

Contact us

Doyle & Ogden Insurance Advisors
3330 Broadmoor, Suite E
Grand Rapids, MI 49512

Get Directions
616-949-9000
info@doyle-ogden.com

Doyle & Ogden Insurance Advisors
3330 Broadmoor, Suite E - Grand Rapids, MI 49512
616-949-9000 | info@doyle-ogden.com
© 2022 Doyle & Ogden Insurance
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