Employee Health Questionnaire Template

1. Name:

The answer should be a text input.

2. Department:

The answer should be a text input.

3. Date of Birth:

The answer should be a text input.

4. Gender:

The answer should be a single choice:

1. Male
2. Female

5. Have you been diagnosed with any underlying health conditions (e.g. heart disease, diabetes, respiratory illness)?

The answer should be a single choice:

1. Yes
2. No

6. Have you been vaccinated against COVID-19?

The answer should be a single choice:

1. Yes
2. No

7. Have you been in close contact with someone who has tested positive for COVID-19 in the past 14 days?

The answer should be a single choice:

1. Yes
2. No

8. Have you experienced any of the following symptoms in the past 14 days? (Please check all that apply)

The answer should be a multiple choice:

1. Fever
2. Cough
3. Shortness of breath
4. Fatigue
5. Loss of taste or smell
6. None of the above

9. Have you travelled outside of your local area in the past 14 days?

The answer should be a single choice:

1. Yes
2. No

10. Have you experienced any discomfort or health problems as a result of your work environment or duties?

The answer should be a single choice:

1. Yes
2. No