DTN Management Co. Wellness Program | Health Risk Assessment
Company Name:
Name:
Date:
In the past 24 hours, have you experienced:
Subjective fever
(felt feverish):
Yes
No
New or worsening cough:
Yes
No
Shortness of breath:
Yes
No
Sore throat:
Yes
No
Diarrhea:
Yes
No
Current Temperature:
In you answered
"yes"
to any of the symptons listed above, or your temperature is
100.4°F or higher
, please do not come into the office. Self-isolate at home and contact your primary care physician's office for direction.
You should isolate at home for a minimum of 7 days since symptoms first appear.
You must also have 3 days without fevers and improvement in respiratory symptoms.
In the past 14 days, have you:
Had close contact with an individual diagnosed with COVID-19?:
Yes
No
If you answered
"yes"
to either of these questions, please do not come into the office. Self-quarantine at home for 14 days.
For questions, visit
hd.ingham/coronavirus
or contact Ingham County Health Department at
(517) 887-4517
.