Daily Health Questionnaire

Today's Date: * +

Student Name: *

Parent/Guardian Name: *

Mobile Number: *

Email *

The full name of the individual filling out this form. *

Section 1: Student Health & Wellness Checklist

Are you experiencing any of the following symptoms or combination of symptoms?

Cough? *

Yes

No

Shortness of Breath? *

Yes

No

Fever (100.4 F or higher)? *

Yes

No

Sore Throat? *

Yes

No

Chills? *

Yes

No

Repeated Shaking with Chills? *

Yes

No

Muscle Aches? *

Yes

No

Headache? *

Yes

No

New Loss of Taste/Smell? *

Yes

No

Has your child been given any fever reducing medication today? *

Yes

No

Has your child been exposed to anyone with a confirmed case of COVID-19 within the last 14 day? *

Yes

No

Has your child been exposed to anyone waiting to receive results of COVID-19 testing? *

Yes

No

Has anyone from your household had to self quarantine in the last 14 days? *

Yes

No

If so, what dates and why?

Has your child tested positive for COVID-19? *

Yes

No

I understand that if I have answered YES to any of the above questions that my child will not be admitted to school TODAY. Also, if my child exhibits any of the above symptoms while at school, I understand that they will be quarantined and will need to be picked up immediately. Please sign by typing your full name below. *