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COVID-19 Symptom Self Report Form
This form must be completed on the day of lesson, prior to arrival at the Mountain
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* Indicates required question
First name
*
Your answer
Last name
*
Your answer
In the past 14 days have you experienced any of these symptoms that are not caused by another condition?
*
yes
no
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
Recent loss of taste or smell
Sore throat
Congestion
Nausea or vomiting
Diarrhea
yes
no
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
Recent loss of taste or smell
Sore throat
Congestion
Nausea or vomiting
Diarrhea
Within the past 14 days, have you had contact with anyone that you know had COVID-19or COVID-like symptoms? Contact is being 6 feet (2 meters) or closer for more than 15 minutes with a person, or having direct contact with fluids from a person with COVID-19?
*
yes
no
Have you had a positive COVID-19 test for active virus in the past 10 days?
*
yes
No
Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?
*
Yes
No
If you answered yes to any of these questions, please explain:
Your answer
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