Reviewed 11/5/2019, Revised 12/6/2019 Revised 03/06/2019, 07/31/2019,08/29/2019, 03/04/2020, 03/06/2020, 03/11/2020, 3/20/2020, 3/24/2020, 4/3/2020, 4/6/2020, 4/24/2020

TRAVEL SCREENING INFORMATION Optim Health System is following the Centers for Disease Control and Prevention travel screening guidelines. Please complete the following questions: HAVE YOU OR ANYONE YOU ARE IN CLOSE CONTACT WITH…

ARE YOU / THEY CURRENTLY EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS?

____________________________________________________________________________________________________ Printed Name: Patient / Visitor Signature Date Time ____________________________________________________________________________________________________ Printed Name: Optim Staff / Employee Date Time Clinical Staff Notification Required? _____Yes _____No ☐ Language/Translation Line Utilized

Do you, or someone in your household, work in a healthcare facility (i.e.: hospital, clinic, nursing home) � Yes � No

Been hospitalized in a facility with COVID-19 patients in the last 14 days? � Yes � No

Been in a nursing home or assisted living facility? � Yes � NoBeen in contact with anyone that has been diagnosed or is being monitored by the CDC for COVID-19 in the last 30 days? � Yes � No

Traveled via any method (i.e. plane, bus, train, ship, car) in or out of the US to an area of widespread COVID-19 transmission in the last 30 days?

� Yes � No

IMAGING ONLY: Have you been sent for imaging due to having COVID-19 signs or symptoms? � Yes � No

OPTIM EMPLOYEES: Do you or anyone in your household, work in other healthcare facilities (i.e.: hospital, clinic, nursing home)

� Yes � No

If yes, what City / State / Country did you / they visit? ______________________________________

If yes, please list the facility name & location ____________________________________________

How frequently do you / they work there? _______________________________________________

When was the last time you / they worked there? _________________________________________

Fever (greater than 100.4°F / 38.0°C) � Yes � NoSevere Headache � Yes � NoMuscle Pain / Weakness � Yes � NoDiarrhea / Vomiting / Abdominal Pain � Yes � NoRespiratory Symptoms / Shortness of Breath � Yes � NoRash / Skin Irritation � Yes � NoUnexplained Bleeding or Bruising � Yes � No