COVID-19 Pre-Screening Questionnaire
The following pre-screening questionnaire must be completed every day by prior to arriving on the grounds.  Please follow all directions on this form including if you should or should not report to practice for the temperature screening.
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Email *
Email Address *
First Name *
Last Name *
Parent/Guardian Name and Phone Number *
Have you had the following symptom in the last 24 hours *
Yes
No
Fever > or =100.4
Cough or Shortness of Breath
Sore Throat
Chills
Muscle aches or rigors
Headache
New loss of taste or smell
Abdominal pain, nausea, vomiting or diarrhea
Have you had close contact with someone who is currently sick? *
Have you been diagnosed with Covid-19 in the past three weeks or have reason to believe you have Covid-19 *
Have you traveled or had close contact with anyone who has traveled internationally in the last 14 days *
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