Visitor health screen

Lutheran Home 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 Lutheran Home is able to welcome scheduled guests onto the campus.

* All fields and answers are required. This health screen must be completed within 24 hours of your visit. If you complete this more than 24 hours in advance, it is not valid.

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

Select One

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

Shortness of Breath
Sore Throat
Shaking with Chills
Muscle Pain
Loss of Taste
Loss of Smell
Runny Nose

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 il with respiratory illness?

Select One

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

Select One

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

Select One

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

Select One
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Tel: (847) 368-7400


800 West Oakton Street

Arlington Heights, Illinois 60004

Empowering vibrant, grace-filled living

across all generations.


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

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