Covid-19 Daily Screening Form

First Name: *

Last Name: *

Email Address: *

Grade: *

Date: *

Month

Day

Year

Parent 1 Email Address: *

Parent 2 Email Address:

Fever/Chills: *

Yes

No

Cough: *

Yes

No

Sore Throat: *

Yes

No

Shortness of Breath: *

Yes

No

Loss of taste or smell:

Yes

No

Runny nose: *

Yes

No

Headache: *

Yes

No

Muscle/Body aches: *

Yes

No

Fatigue: *

Yes

No

Diarrhea: *

Yes

No

Nausea/Vomiting: *

Yes

No

Close contact with someone confirmed with Covid-19: *

Yes

No

Have you taken any fever reducing/pain medication in the past 24 hours: *

Yes

No

Is anyone sick in your household?: *

Yes

No

Temperature if over 100.3 degrees:

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