Monsignor Edward Pace High School
Student Form
Daily Wellness Survey
Name
*
First Name
Last Name
Grade Level
*
9th Grade
10th Grade
11th Grade
12th Grade
1. In the last 48 hours have you had a fever or chills?
*
No
Yes
2. Do you have a constant uncontrollable cough?
*
No
Yes
3. Do you have shortness of breath or difficulty breathing?
*
No
Yes
4. Are you experiencing any fatigue or body aches?
*
No
Yes
5. Have you had a new onset of severe headaches?
*
No
Yes
6. Have you recently lost your ability to taste and smell?
*
No
Yes
7. Are you experiencing severe congestion or a runny nose?
*
No
Yes
8. Do you have severe diarrhea, vomiting, or abdominal pain?
*
No
Yes
9. Do you have a sore throat?
*
No
Yes
10. Have you had close contact with someone who has COVID-19?
*
No
Yes
DateTime
Submit
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