EPHS Alpine Health Check Form

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Daily Self Screen Health Check

Have you/your athlete within the last 14 calendar days: Been in close and prolonged physical contact (within 6ft or less for 15 minutes) with someone diagnosed with COVID-19? Been diagnosed with COVID-19? *

Yes

Do you/your athlete have new or worsening onset of any of the following symptoms that you cannot attribute to another health condition? Fever of 100.4 or higher, feeling feverish, chills, a new cough, shortness of breath, a new sore throat, new muscle aches, new loss of taste or smell, new gastrointestinal symptoms such as diarrhea, vomiting or nausea? *

Yes

Have you/your athlete been advised by a medical provider or health authority that an exposure to COVID-19 has occurred? *

Yes

I/my athlete have traveled outside of the recommended guidelines by the Center of Disease Control and/or local government ? *

Yes

If you answered YES to any of the above DO NOT attend any team events until you have talked with a coach via phone and received further instruction. Do you understand this statement? *

Yes

Name *

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