Name: Luther Oaks
Address: 601 Lutz Road, Bloomington, IL, 61704
Telephone: (309) 557-8000

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(309)557-8000

601 Lutz Road,

Bloomington, Illinois 61704

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VISITOR HEALTH SCREEN

Luther Oaks requests your help to reduce community risks to the spread of COVID-19. For the residents, team members, and other visiting family members and guests, please complete the following health screen questions.

The completion of this health screen is required by the Illinois Department of Public Health.
Before each scheduled visit, the completion of this health screen is mandatory before Luther Oaks is able to welcome scheduled guests onto the campus.

* All fields and answers are required:

How many visitors for this scheduled visit?
(If two, second visitor must also complete this form)

Select One:

One

Two

In the last 14 days, have you experienced any of the following signs or symptoms of COVID-19?

Fever

Yes

Cough

Yes

Shortness of Breath

Yes

Sore Throat

Yes

Chills

Yes

Shaking with Chills

Yes

Muscle Pain

Yes

Headache

Yes

New Loss of Taste

Yes

New Loss of Smell

Yes

Fatigue

Yes

Congestion

Yes

Runny Nose

Yes

Nausea

Yes

Vomitting

Yes

Diarrhea

Yes

In the last 14 days, have you come in contact with anyone who has a confirmed case of COVID-19, is under investigation for COVID-19, or ill with respiratory illness?

Select One

Yes

In the last 14 days, have traveled anywhere with widespread, ongoing transmission of COVID-19?

Select One

Yes

In the last 14 days, have you been on a cruise ship or been in an airport?

Select One

Yes

Are you, or anyone in your party, 18 years old or younger?

Select One

Yes

Thank you.
Your health screen has been delivered.

Tel: (309) 557-8000

Address

601 Lutz Road,

Bloomington, Illinois 61704

A 501(c)3 not-for-profit corporation

Empowering vibrant, grace-filled living

across all generations.

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