Health Questionnaire

SD Force FC- Health Screening Questionnaire Related to COVID-19
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes No
Are you/they having shortness of breath or other difficulties breathing? *

Yes No
Do you/they have a cough *

Yes No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes No
Have you/they experienced recent loss of taste or smell? *

Yes No
Participants who are well but who have a sick family member at home with COVID-19 or answer YES to ANY of the above should not practice.
Date *

Month Day Year
Date
Location
Player Name *
Division *
Age Group *
Coach *
Parent/Guardian Signature *

Clear
Should be Empty:

SD Force FC- Health Screening Questionnaire Related to COVID-19