Health Screening Questionnaire Template

Screen people for illness symptoms before they arrive at a workplace, school, clinic or event — or before a booked appointment or shift, using the optional appointment fields. It covers current symptoms and when they started, temperature and anything taken to bring one down, exposure and travel where a policy acts on them, vaccination status where a requirement applies, and an acknowledgement of what you ask people to do if they are unwell. Every screening question carries an instruction to check it against current public-health advice and your own policy and delete what you will not act on, because this is the template that dates fastest. The questions here were written on 22 August 2026.

Use this template

Last updated 21 August 2026

Fields in this template

Full Namerequired
Email Addressrequired
Date of Birth
Employer, School, or Event Name
Appointment, Visit or Shift Date
Appointment Time, Clinician or Department
Has your temperature been taken today?
Yes — it was normal (below 100.4°F / 38°C) · Yes — it was elevated · No, it has not been taken
Have you taken anything to bring a temperature down in the last eight hours?
Yes · No · I'm not sure
Are you currently experiencing any of the following symptoms?required
Fever or chills · Cough (new or worsening) · Shortness of breath · Fatigue or body aches · Headache · Sore throat · Loss of taste or smell · Nausea, vomiting, or diarrhea · Runny nose or congestion · None of the above
If you have symptoms, when did they start?
Have you traveled internationally or to a high-risk area in the past 14 days?
Yes · No
In the past 14 days, have you had close contact with someone confirmed to have a contagious illness?
Yes · No · I'm not sure
Are you up to date on recommended vaccinations for this setting?
Yes, fully vaccinated and up to date · Partially vaccinated · Not vaccinated · Prefer not to say
Policy Acknowledgementrequired
I have read the policy above, my answers are accurate as of today, and I will get in touch rather than attending if anything changes before I arrive.
Additional Health Notes

Who uses this template

Healthcare facilitiesGP, dental and allied health practicesEmployers and HR teamsSchool administratorsEvent organizersLong-term care facilitiesGyms and fitness centersCommunity organizationsGovernment agenciesPractice and office managers writing an attendance policy

About this template

A health screening questionnaire asks a short set of questions about symptoms, exposure and vaccination status before someone arrives — at a workplace, a school, an event, a care home or a clinic. Filled in before arrival rather than at a desk, it produces a searchable record and removes the queue at a single check-in point. This template covers the core dimensions: current symptoms and when they started, whether a temperature has been taken and whether anything has been taken to bring one down, recent travel and close contact where a policy acts on them, and vaccination status where a requirement applies. The optional appointment date, time and clinician fields let the same form screen a booked patient, visit or shift, where the useful outcome is moving the appointment before the person travels rather than turning them away at a door.

The questions were written on 22 August 2026, and that date is printed on the form and not only here. It matters more on this template than on any other: symptom lists, exposure windows, travel questions and vaccination requirements all change with guidance and by setting, and a screening form left untouched for two years asks the wrong questions with complete confidence. The 14-day windows in the travel and close-contact questions are a case in point — they are placeholders inherited from a particular moment in public-health history, not advice, and each question now says so and asks you to substitute your own window or delete the question. Every screening field carries the same instruction: check it against the advice that currently applies where you are, and delete it if nothing acts on the answer. formformform does not monitor or update the content of a cloned form; keeping it current is yours to do, and the template says so plainly.

The required set is deliberately short — name, email, the symptom checklist and the policy acknowledgement. Date of birth, travel, close contact and vaccination status are all optional, because asking every visitor for an international travel history at every visit collects sensitive data most settings never use. The policy paragraph ships with default wording saying that an appointment moved because someone is unwell is not treated as a late cancellation, which is worth keeping: a policy that penalizes staying away when unwell produces exactly the answers it deserves. formformform hosts every form in the EU and handles submissions under GDPR, and optional end-to-end encryption can be switched on per form before the first response arrives. Nothing here makes an organization compliant with HIPAA or any other regime, and this form is not triage, diagnosis or a public-health instrument.

17 form ideas you can build with this template

Employee Daily Health Screening Form

Sent to all staff each morning before entering a workplace, logging symptom status and temperature to maintain a daily safety record.

School Student Health Screening Form

Used by school nurses or administrators to screen students at the start of each day or after a return from illness or travel.

Healthcare Facility Visitor Health Screening

Required for all visitors entering a hospital, clinic, or long-term care facility to protect immunocompromised patients and vulnerable residents.

Event Attendee Pre-Entry Health Check

Sent to conference, concert, or sporting event attendees before the day of the event to identify anyone who should not attend in person.

Gym or Fitness Center Member Health Check-In

Requires members to complete a symptom screening before entering the facility, particularly for high-contact group fitness classes.

Restaurant or Food Service Pre-Shift Screening

Screens food handlers before each shift for GI symptoms, fever, or jaundice — required by most food safety codes.

Summer Camp Health Screening Form

Collects symptom and vaccination status information from campers and staff at the start of each camp session.

Elder Care Facility Visitor Screening

Screens all visitors to nursing homes or assisted living facilities before they enter the building to protect high-risk residents.

Surgery Center Pre-Operative Health Screening

Screens patients the morning of a procedure for fever, respiratory symptoms, or recent illness that could affect surgical safety.

University Campus Return-to-Campus Screening

Used by universities to screen students, faculty, and staff returning from breaks, travel, or quarantine periods.

Clinical Trial Pre-Visit Health Screening

Screens research study participants before each study visit for symptoms that would require a visit postponement per protocol.

Corporate Health Fair Attendee Screening

Screens employees before they enter a workplace health fair or biometric screening event to protect vendors and staff.

Immigration Health Screening Questionnaire

Used at border health checkpoints or immigration processing centers to screen travelers for symptoms of communicable disease.

Post-Exposure Symptom Monitoring Form

Used to track symptoms over a defined monitoring period for individuals who have had known exposure to a communicable illness.

Clinic Pre-Appointment Screening

Sent with an appointment reminder so a symptomatic patient is moved to a later slot, or offered a remote appointment, before they travel to the clinic.

Dental Practice Pre-Appointment Screening

Screens for symptoms before a chairside appointment where a patient and clinician cannot be kept apart.

Home Visit Pre-Attendance Check

Screens a household before a clinician or support worker travels to them, where turning back at the door costs an entire visit.

What's included

The questions carry the date they were written — 22 August 2026, stated at the top of the form itself and not only on this page

The symptom checklist carries a review instruction: check the options against current public-health advice and your own policy before publishing

Works both at a door and before a booking — optional appointment date, time and clinician or department fields

A policy paragraph with usable default wording, plus a required acknowledgement written to match it

Symptom onset date and a question about fever-reducing medication, both of which change how a symptom answer reads

Travel, exposure and vaccination questions all ship optional, each with an instruction to delete it unless your policy acts on the answer

Date of birth ships optional — most screenings match to a person on a name and a date

An emergency instruction above the questions: a screening form is not the route for someone who is seriously unwell

Temperature reporting field for venues that also screen on site

Employer, school or event name field lets one form cover several locations

Fast to complete — about two minutes on any device

How to create a health screening questionnaire

1
Click "Use this template" to open the health screening questionnaire in the formformform builder.
2
Read every screening question against your own policy and the public-health advice that currently applies where you are, and delete the ones nothing will act on. This step is the point of the template.
3
Edit the symptom checklist for your setting — a food service context emphasizes gastrointestinal symptoms; a respiratory ward emphasizes others.
4
Replace the 14-day windows in the travel and close-contact questions with the window your own policy uses, or delete those questions.
5
Replace the policy paragraph with your own wording, including what happens to a fee, a shift or an attendance record when someone stays away, and check that the acknowledgement sentence still matches it.
6
Decide how the form is used: keep the appointment date, time and clinician fields and make the date required when you are screening booked appointments, or delete them when you are screening arrivals at a location.
7
Delete the guidance text from the field descriptions, and trim the reviewer note from the opening paragraph, once you have acted on them — keep the date and the emergency instruction, which respondents should see.
8
Update the date in the paragraph at the top of the form to the day you reviewed the questions, and put the next review in your own calendar.
9
Publish, then send the link with the appointment reminder or shift rota, or post a QR code at the entrance — early enough that you can still act on an answer.

Best practices for your health screening questionnaire

Date the questions on the form, not just in your notes. Screening content ages faster than anything else an organization publishes, and a visible date is what makes someone check it. The version that ships says 22 August 2026

change it to the day you last reviewed it.

Delete every question nothing acts on. If a yes to travel changes nothing, the question collects sensitive data for no benefit and somebody still has to look after it.

Replace vague or inherited windows with your own numbers. The 14 days in two of these questions came from a specific moment in public-health history; whatever your policy says today, put that in the question.

Deploy before arrival, not at the door. Screening sent by email or QR code the morning of a shift, or with an appointment reminder, removes the entry-point queue and leaves time to act on a flagged answer.

Make the outcome a reschedule or a rota change, not a refusal. A form that reads as a checkpoint gets answered dishonestly. Say clearly that an appointment or shift moved for illness is not penalized, and mean it.

Keep the emergency instruction at the top. Somebody genuinely unwell must not sit waiting for a reply to a form, and the instruction belongs above the questions, not under the submit button.

Have a protocol for every yes before you publish. Decide who reads flagged responses and what they do, and turn on email notifications so they know as soon as one arrives. A form without a follow-up process is just a liability document.

Do not ask for vaccination status unless a requirement applies, and name the specific vaccinations when it does. A general 'are you up to date' question invites an answer nobody can act on.

Keep date of birth optional unless you genuinely need a second identifier. Most screenings match to a person on a name and a date.

Do not promise anonymity. You hold the key to an encrypted form and can read every answer, and every submission is stored with a timestamp and the respondent's IP address, which sits outside the encrypted payload and appears in the CSV export. Promise confidentiality

that answers are used for safety and not for discipline — and keep that promise, rather than promising something the form cannot deliver.

Set a retention rule before you publish. Screening answers stop being useful very quickly; decide when they are deleted, say so on the form, and do it.

Do not claim compliance. EU hosting and GDPR handling are real and can be stated. SOC 2 and ISO 27001 belong to the hosting provider, and no form makes an organization HIPAA compliant.

Frequently asked questions

When were these screening questions written?

22 August 2026. The date is on the form as well as here, because this template dates faster than anything else in the library. The questions are not maintained against changing public-health guidance — check them against your own policy and the advice that currently applies where you are before you publish, and change the date on the form to the day you did.

Why do the travel and close-contact questions still say 14 days?

Because that window is what the template inherited, and rewriting it to a different number would just be a different guess. Both questions now ship optional and both carry an instruction to replace 14 days with the window your own policy uses, or to delete the question if nothing acts on the answer.

Can I use this before a booked appointment as well as at a door?

Yes — that is what the optional appointment date, time and clinician or department fields are for. Make the appointment date required when every respondent has a booking, so a symptomatic patient can be moved or offered a remote alternative before they travel. Delete those fields when you are screening arrivals at a location instead.

Can I use this form as an employee daily health screening?

Yes. Send the link each morning by email or chat, or post a QR code at the building entrance. Submissions are timestamped, so you have a clear daily record of who completed screening and when.

Can I require all event attendees to complete screening before entry?

Yes. Include the form link in your registration confirmation email and make it clear that a completed screening is required for entry. For events, you can also post a QR code at the door for walk-ins.

Should I keep the exposure, travel and vaccination questions?

Only if your policy acts on the answers. All three ship optional and each carries an instruction to delete it otherwise. Collecting an exposure history that changes nothing gives you sensitive data to look after and gives the respondent no benefit.

Is the symptom checklist specific to one illness?

No. It covers general respiratory and gastrointestinal symptoms as written on 22 August 2026 and is not tied to any particular pathogen or to any current guidance. Edit the list for the illnesses your setting actually screens for.

How do I handle respondents who report symptoms?

The form collects information; it does not decide anything. Your team needs a defined protocol — typically the person is asked not to attend and is directed to their usual healthcare service, and an appointment or shift is moved. Turn on email notifications so whoever owns that decision knows a response has arrived and can open it straight away.

Can I tell people their answers are anonymous?

No, and you should not. You can read every response, including on a form with end-to-end encryption switched on, because you hold the key — and each submission is stored with a timestamp and an IP address that sits outside the encrypted payload and appears in the export. Tell people the truth instead: answers are confidential, used for safety, and not used for discipline. That is what makes them honest.

Can I translate this form into another language?

Yes. Every field label, option and paragraph is editable in the formformform builder, so you can translate the form in place or duplicate it and keep a version per language.

Is this form free?

Yes. Use it, customize it and collect unlimited submissions at no cost, with no per-submission fees.