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ECC & RS Health Screening Questionaire
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GHC ECC and RS Health Screening Questionaire
Does your child have or have had in the past 14 days:
Fever
Chills
Sweats
Measured temperature of 100.4F or greater
Maiaise/Fatigue
Loss of sense of smell
Loss of sense of taste
Cough
Chest Pain
Shortness of Breath
Sore Throat
Nausea
Vomitting
Diarrhea
Have you or your child been in direct contact with someone that tested positive for Covid-19 in the past 14 days?
Have you or your child been diagnosed with Covid-19 within the past 14 days
Has your child traveled internationally in the past 14-days
Has your child traveled by air, car or train, out of the tristate area in the past 14 days?
*
Printed Child's Name
*
Parent/Legal Guardian who completed this form
*
Email address
*
Date
Fri, May 20 2022 19 Iyyar 5782