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COVID-19 Daily Health Pre-Screen Questionnaire

A pre-shift or pre-visit health screening for workplaces, clinics, and event venues that checks symptoms, exposure risk, and testing status before entry. An AI follow-up interview clarifies ambiguous or borderline symptom answers so staff can make a fast, consistent go/no-go decision.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

11 questions · ~6 min
Q01
Message

Welcome! Before you head in today, please complete this quick health check-in. It takes about 7 minutes and helps keep everyone on-site safe.

Q02
Short TextRequired

What is your full name?

Q03
DateRequired

What is today's date?

Q04
Multiple ChoiceRequired

In the last 24 hours, have you experienced any of the following symptoms? (Select all that apply)

  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Sore throat
  • Loss of taste or smell
  • Runny nose or congestion
  • Fatigue or body aches
  • Nausea, vomiting, or diarrhea
Q05
Multiple ChoiceRequired

In the last 10 days, have you tested positive for COVID-19?

  • Yes, and I am still within my isolation period
  • Yes, but my isolation period has ended
  • No
  • I have not been tested
Q06
Multiple ChoiceRequired

In the last 10 days, have you had close contact with someone who tested positive for COVID-19?

  • Yes
  • No
  • Not sure
Q07
Opinion ScaleRequired

Overall, how would you rate your general health today?

Scale: 1 – 5
Min:Very poorMax:Excellent
Q08
Multiple Choice

Have you taken a temperature reading today?

  • Yes, below 100.4°F (38°C)
  • Yes, 100.4°F (38°C) or above
  • No
Q09
AI Interview

If the respondent reported any symptoms, a positive test within the isolation period, or recent close contact, probe for specifics: which symptoms, when they started, whether they've improved or worsened, and whether they've taken any medication that could be masking a fever. If answers suggest they should not be on-site (active symptoms, unresolved isolation, or close contact within 10 days), state that clearly and note it for staff review. If the respondent reports no symptoms and no exposure, keep this brief and confirm there's nothing else notable.

Q10
ConsentRequired

Please confirm the statement below before proceeding.

Q11
Message

Thanks for checking in! Your responses are reviewed by on-site staff to help decide next steps, and are kept confidential and used only for health and safety purposes.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Combines the standard symptom, exposure, test-status, and temperature questions with an AI follow-up interview that automatically clarifies ambiguous or borderline symptom answers so staff reach a fast, consistent go/no-go decision — something a static form cannot do.
  • Includes an explicit consent step built into the flow before the respondent can proceed, keeping the compliance record self-contained.
  • Auto-generates a report for on-site staff review, reducing manual triage of free-text or inconsistent answers.
  • Uses chat-style welcome and closing messages to keep the daily check-in fast and low-friction for repeat use before every shift or visit.

Jotform

COVID-19 Daily Health Screening Form Template

A ready-to-field static form covering symptoms, exposure, and temperature checks, built on Jotform's drag-and-drop form builder. It's easy to deploy and customize with Jotform's wider ecosystem of integrations, but it functions as a fixed questionnaire rather than an interactive screening interview.

What it does well

  • Fielding-ready template within a mature, widely-used form builder
  • Easy to customize fields and branding via drag-and-drop editor
  • Likely integrates with Jotform's broader suite (notifications, storage, e-signature)

Where it falls short

  • No adaptive follow-up questioning to clarify vague or borderline symptom responses
  • No automated quality scoring of individual responses
  • No published methodology or transparent prompt logic since there are no AI-driven questions

SurveySparrow

COVID Screening Questionnaire Template

A fielding-ready, conversational-style survey template for daily COVID pre-screening, benefiting from SurveySparrow's chat-like question flow that feels more personable than a traditional form. It still delivers a fixed question sequence rather than dynamically probing uncertain answers.

What it does well

  • Conversational one-question-at-a-time format for a friendlier check-in feel
  • Fielding-ready template designed specifically for COVID pre-screening
  • Likely mobile-friendly given SurveySparrow's chat-style UI focus

Where it falls short

  • No adaptive AI interview to follow up on ambiguous symptom or exposure answers
  • No automated per-response quality scoring
  • No option for a voice-based interview component

QuestionPro

Workplace Health and Safety Questionnaire

This is a general workplace health and safety questionnaire rather than a template purpose-built for daily COVID-style pre-screening, so it's broader in scope and would need adaptation for a fast pre-shift go/no-go check. It's fielding-ready within QuestionPro's survey platform but not tailored to symptom/exposure triage specifically.

What it does well

  • Backed by QuestionPro's established enterprise survey platform and reporting tools
  • Covers broader workplace safety topics beyond just infectious-disease screening
  • Fielding-ready and customizable within their survey builder

Where it falls short

  • Not purpose-built for daily symptom/exposure pre-screening, requiring rework for that specific use case
  • No adaptive AI follow-up to clarify borderline health responses
  • No automated quality scoring or auto-generated go/no-go style reports

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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