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Daily Covid-19 Pre-screen Health Survey
Each Day before you attend summer workouts you MUST fill out this form and have your temperature checked..
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* Indicates required question
Today's Date*
*
MM
/
DD
/
YYYY
Sport
*
Football
MSOC
WTEN
XC
VB
CHEER
Are you a... (check one)
*
Coach
Athlete
Required
Last Name
*
Your answer
First name
*
Your answer
Have you had Racing, Fluttering, or Skipping Beats of Heart?
*
Yes
No
Have you had Unusual Dizziness During or After Exercise?
*
Yes
No
Have you had a cough or shortness of breath?
*
Yes
No
Have you had a sore throat?
*
Yes
No
Have you had a new loss of taste or smell?
*
Yes
No
Have you had vomiting or diarrhea?
*
Yes
No
Have you been in close contact with someone diagnosed with COVID-19?
*
Yes
No
Has a member of your household been diagnosed with COVID-19?
*
Yes
NO
Have you had a fever in the last 24 hours?
*
Yes
No
Temperature Reading
*
Your answer
Is their temperature over 100.4 F?
*
Yes
No
Was the athlete held from participation in workouts due to symptoms?
*
Yes
No
If held from participation, what is parent's name?
Your answer
If held from participation what is parent's phone number?
Your answer
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