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.
Free for non-commercial projects, with unlimited forms and responses.
Last updated
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.
Use your own copy to change labels, remove questions and add the details you need. Try the preview alongside this guide to see what respondents will be asked.
Review the starting questions and choices. You can change them in your own copy.
Jane Doe
you@email.com
Acme Corp, Springfield High School, Annual Health Fair, etc.
e.g. 10:30, Dr Rivera, physiotherapy
Any other health information relevant to today's visit or event
Suggested uses, and why this starting point can help. Adapt the questions to your own process.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Date of Birth” in particular and adapt it to the detail you need.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Appointment, Visit or Shift Date” in particular and adapt it to the detail you need.
Collect a consistent starting point for review, so the next conversation can focus on suitability and missing details rather than repeating basic questions. Review “Appointment Time, Clinician or Department” in particular and adapt it to the detail you need.
Used by school nurses or administrators to screen students at the start of each day or after a return from illness or travel.
Gather the details needed before making arrangements. Consistent answers help you spot special requirements and prepare the next step. Review “Have you taken anything to bring a temperature down in the last eight hours?” in particular and adapt it to the detail you need.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Are you currently experiencing any of the following symptoms?” in particular and adapt it to the detail you need.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “If you have symptoms, when did they start?” in particular and adapt it to the detail you need.
Gather the details needed before making arrangements. Consistent answers help you spot special requirements and prepare the next step. Review “Have you traveled internationally or to a high-risk area in the past 14 days?” in particular and adapt it to the detail you need.
Get a useful brief before the first conversation. Written context helps you assess fit, prepare questions and decide what to discuss next. Review “In the past 14 days, have you had close contact with someone confirmed to have a contagious illness?” in particular and adapt it to the detail you need.
Replace scattered requests with a consistent starting point. The answers help you understand the work, identify gaps and prepare a follow-up. Review “Are you up to date on recommended vaccinations for this setting?” in particular and adapt it to the detail you need.
Click "Use this template" to open the health screening questionnaire in the formformform builder.
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.
Edit the symptom checklist for your setting — a food service context emphasizes gastrointestinal symptoms; a respiratory ward emphasizes others.
Replace the 14-day windows in the travel and close-contact questions with the window your own policy uses, or delete those questions.
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.
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.
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.
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.
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.
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.
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.
Sent to all staff each morning before entering a workplace, logging symptom status and temperature to maintain a daily safety record.
Used by school nurses or administrators to screen students at the start of each day or after a return from illness or travel.
Required for all visitors entering a hospital, clinic, or long-term care facility to protect immunocompromised patients and vulnerable residents.
Sent to conference, concert, or sporting event attendees before the day of the event to identify anyone who should not attend in person.
Requires members to complete a symptom screening before entering the facility, particularly for high-contact group fitness classes.
Screens food handlers before each shift for GI symptoms, fever, or jaundice — required by most food safety codes.
Collects symptom and vaccination status information from campers and staff at the start of each camp session.
Screens all visitors to nursing homes or assisted living facilities before they enter the building to protect high-risk residents.
Screens patients the morning of a procedure for fever, respiratory symptoms, or recent illness that could affect surgical safety.
Used by universities to screen students, faculty, and staff returning from breaks, travel, or quarantine periods.
Screens research study participants before each study visit for symptoms that would require a visit postponement per protocol.
Screens employees before they enter a workplace health fair or biometric screening event to protect vendors and staff.
Used at border health checkpoints or immigration processing centers to screen travelers for symptoms of communicable disease.
Used to track symptoms over a defined monitoring period for individuals who have had known exposure to a communicable illness.
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.
Screens for symptoms before a chairside appointment where a patient and clinician cannot be kept apart.
Screens a household before a clinician or support worker travels to them, where turning back at the door costs an entire visit.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Yes. Use it, customize it and collect unlimited submissions at no cost, with no per-submission fees.
Collect patient info, medical history, and insurance before the appointment.
Take appointment requests with date, time, service type, and reason.
Collect complete patient medical history before appointments.
Collect informed consent and appointment details before virtual visits.
Streamline new and existing dental patient registration online.
Streamline new and returning patient intake for eye care clinics.
Let patients request prescription refills online, anytime.
Evaluate new clients' goals, fitness level, and health history.
Explore how formformform fits the forms you need to build.
Opens with product context and a link to this page.
Free for non-commercial projects, with unlimited forms and responses.
Use this template