COVID-19 Daily Health and Wellness Checklist

• Conducted on

  Date

• Prepared by

• For more health and wellness practices, follow the CDC's Checklist for Individuals and Families @
  https://www.cdc.gov/coronavirus/2019-ncov/community/home/checklist-household-ready.html

Plan and Prepare

• Within the last 14 days have you or anyone in your household had close contact with someone that is in the process of being tested or has tested positive for COVID-19?

  Yes

  No

• Within the last 14 days have you or anyone in your household experienced any of the following: Fever or Flu-like symptoms; Cough; Trouble Breathing; Shortness of Breath; Chills; Repeated Shaking with Chills; Muscle Pain; Headache; Sore Throat; or New Loss of Taste or Smell?

  Yes

  No

• Within the last 14 days have you or anyone in your household traveled outside the US or to any area with a known COVID-19 outbreak?

  Yes

  No