JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Majestic Adventures Health Screening
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name of Child/Participant
*
Please include first and last name
Your answer
Symptoms
Has your child experienced any of these symptoms in the last 3 days? Please select all that apply.
Fever (100.4 or higher) or a sense of having a fever
Chills
Cough
Shortness of breath or difficulty breathing
Sore throat
Unusual Fatigue
Muscle/body aches
New loss of taste/smell
Nausea/Vomiting/Diarrhea
Congestion/running nose – not related to seasonal allergies
None of the above
Other:
Attributable to Other Condition?
If you checked any of the boxes above, are any of those symptoms attributable to another condition? Please explain below.
Your answer
Close Contact
Has your child or been in sustained close contact (such as sharing a household) with someone who has been sick with COVID-19 or another highly transmissible illness?
Yes
No
Maybe
Other:
Clear selection
Tested Positive?
Has your child tested positive for COVID-19 or another transmissible illness in the past 10 days?
Yes
No
Maybe
Other:
Clear selection
Quarantine
Within the past 14 days, has a public health or medical professional told your child to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection or other transmissible disease?
Yes
No
Maybe
Other:
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of majesticadventures.net.
Report Abuse
Forms
