NDS After School PE Health Check

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Other Name not in drop down menu

Date *

YYYY

What grade or cohort are you in? *

1/2

3/4

5/6/7/8

What is your temperature? *

Do you have a cough, runny nose, sore throat, or shortness of breath? *

Yes

Do you have any flu-like symptoms (fatigue, chills, muscle aches) *

Yes

Have you had gastrointestinal issues (nausea, vomiting, or diarrhea) within the last 24 hours? * *

Yes

Have you taken any symptom relieving medication? (Tylenol, Ibuprofen, cough medicine, Lozenges, any allergy medication) in the last 24 hours? *

Yes

Do you have a doctor's note or other proof that these symptoms are a result of allergies or other non-communicable ailments? *

Yes

Has anyone in your immediate family/household been diagnosed with COVID-19? *

Yes

Have you traveled outside of our state or country in the last 14 days? *

Yes

Clear form

Never submit passwords through Google Forms.

This form was created inside of Notre Dame School. Report Abuse