Healthcare Temperature Document

HEALTHCARE TEMPERATURE DOCUMENT

This record documents temperature screening conducted for infection control and clinical triage. Temperature measurements and related screening responses entered on this form become part of the patient's medical record and may be used for clinical decision-making, isolation, referral, and reporting as required by facility policy and applicable law. The patient (or authorized representative) certifies that the information provided is accurate and complete to the best of their knowledge.

Patient Information

Insurance Information

Relevant Medical History

Screening Event

Screening Date:    Time:    Location:

Temperature Measurements

Reading 1

Time:    Temperature:    Unit:    Method:

Site:    Device ID / Serial:    Measured by:

Reading 2

Time:    Temperature:    Unit:    Method:

Site:    Device ID / Serial:    Measured by:

Reading 3

Time:    Temperature:    Unit:    Method:

Site:    Device ID / Serial:    Measured by:

Symptoms & Exposure

Indicate current symptoms (check all that apply):

Fever or chills    Cough    Shortness of breath    Sore throat

New loss of taste or smell    Unexplained fatigue    None of the above

Exposure in the past 14 days:

Recent travel to high-risk area    Close contact with confirmed case

Actions Taken

Allowed to proceed with visit    Mask provided / monitored    Referred for clinical evaluation   

Denied entry or services    Placed in isolation pending assessment

Device & Calibration

Privacy Acknowledgment & Certification

I acknowledge that temperature readings and screening responses are recorded in the facility medical record for purposes of clinical triage, infection control, and reporting as required. I understand that screening is performed according to facility protocol and that elevated measurements may result in additional evaluation, isolation, or referral.

I acknowledge receipt of the screening record and understand the uses described above.

By signing below, I attest that the information I have provided on this form is accurate and that I understand the consequences of knowingly providing false information. I further attest that temperature readings were taken in accordance with the device manufacturer's instructions and facility protocol, and that any abnormalities were communicated to me along with next steps.

Patient / Representative attests that the foregoing statements are true and complete.

Sign Now