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COVID19 questionnaire

 
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Today's date
Child's name
Parent's/ guardian's name

Today or in the past 24 hours, have you or any household members had any of the following symptoms?

Fever (temperature of 100.0°F or above), felt feverish, or had chills?
Cough?
Sore throat?
Difficulty breathing?
Gastrointestinal symptoms (diarrhea, nausea, vomiting)?
Abdominal pain?
Unexplained rash
Fatigue
Headache?
New loss of smell/taste?
New muscle aches?
Any other signs of illness?
In the past 14 days, have you had close contact with a person known to be infected with the novel coronavirus (COVID-19)

If any of the symptoms detected, contact “Az-Book-Ah!” Kids Center to notify of the health condition and contact the physician to get checked for COVID-19.

I have performed visual screening of my family members.

Make sure to perform visual screening of your family members!
Make sure to perform visual screening of your family members!
Make sure to perform visual screening of your family members!
Make sure to perform visual screening of your family members!

Electronic signature (your name)