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COVID-19 Questionnaire

On the day of the visit all visitors will be required to fill out Briarwood Manor’s COVID-19 questionnaire.

Please answer the following truthfully.  If you answer “yes” to any question you will not be allowed to enter the building. If you are not truthfully in answering the questions your visitation privileges will be suspended.  Protecting all of our residents and staff is our top priority. 

You will be screened before entering the facility and may be denied entry based on results of the screening.  

COVID-19 Questionnaire Guest 1

    Gender:

    Temperature Over 100.0:

    Dry Cough:

    Sore Throat:

    Headache:

    Fatigue:

    Loss of Smell or Taste:

    Body Aches:

    Diarrhea / Upset Stomach / Vomiting:

    Shortness of Breath:

    Have you tested positive for COVID-19 in the past 14 days?

    Have you or anyone in your household had close contact with anyone who has COVID-19 or symptoms of COVID-19 in the past 14 days?

    Have you completed two doses of COVID-19 vaccine. Has it been 14 days since the second dose, and within 90 days of that dose? (Please provide documentation when checking in for your visit.)

    COVID-19 Questionnaire Guest 2

      Gender:

      Temperature Over 100.0:

      Dry Cough:

      Sore Throat:

      Headache:

      Fatigue:

      Loss of Smell or Taste:

      Body Aches:

      Diarrhea / Upset Stomach / Vomiting:

      Shortness of Breath:

      Have you tested positive for COVID-19 in the past 14 days?

      Have you or anyone in your household had close contact with anyone who has COVID-19 or symptoms of COVID-19 in the past 14 days?

      Have you completed two doses of COVID-19 vaccine. Has it been 14 days since the second dose, and within 90 days of that dose? (Please provide documentation when checking in for your visit.)

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