Health Screening Questionnaire Health Screening Questionnaire Health Screening QuestionnairePARENTS / GUARDIAN / STAFF MUST FILL OUT THIS QUESTIONNAIRE TO DECIDE IF THE CHILD SHOULD ENTER TODAY.Student Name*Do you, or your child attending the program, have any of the below symptoms:Fever*YesNoCough*YesNoShortness of Breath / Difficulty Breathing*YesNoSore throatYesNoChills*YesNoPainful swallowingYesNoRunny Nose / Nasal CongestionYesNoFeeling unwell / Fatigued*YesNoNausea / Vomiting / Diarrhea*YesNoUnexplained loss of appetite*YesNoLoss of sense of taste or smell*YesNoMuscle/ Joint aches*YesNoHeadache*YesNoConjunctivitis (Pink eye)*YesNoHas your child travelled outside of USA in the last 14 days or has someone in the household travelled outside of USA in the last 14 days and is ill?*YesNoHave you or your children attending the program had close unprotected* contact (face-to-face contact within 2 metres/6 feet) in the last 14 days with someone who is ill with cough and/or fever?*YesNoHave you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*YesNoSignature*Name*Parent Email* Date* Date Format: MM slash DD slash YYYY
