St. George School

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St. George School

Health Screening Checklist. For appointments please call (909-984-9123)

Today's Date and Appointment Time (screening should be filled out the day of your appointment) *

YYYY

Time

Name *

Phone Number *

Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? *

Yes

Referring to the previous question. If yes, when did your symptoms begin? When did your symptoms disappear?

Have you or anyone in your household been tested for COVID-19 *

Yes

Referring to the previous question. If yes, when were you or your household tested? And when was the last time you or your household showed symptoms?

Have you or anyone in your household traveled in the U.S. in the past 21 days? *

Yes

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? *

Yes

Have you or anyone in your household traveled on a cruise ship in the last 21 days? *

Yes

Are you or anyone in your household a health care provider or emergency responder? *

Yes

Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19 *

Yes

Referring to the previous question. If yes, how long ago?

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? *

Yes

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? *

Yes

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