Health Screening Form

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Student-athlete, please fill out the following form prior to sport with parent/guardian. If you have answered yes to any questions, please stay home and follow-up with a physician. If a student-athlete's temperature is above 100.0 he or she is to stay home OR answers YES to any of the questions.

Email *

Student-athlete name *

Today's Date *

YYYY

Do you have any of the following symptoms? *

Fever above 100.4° F or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

Loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

No Symptoms - Symptom Free

Have you been in close contact or cared for someone with COVID-19? *

Yes

Maybe

Have you traveled to a "hot-spot" for COVID-19? *

Yes

Maybe

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