Wild Roots COVID-19 Initial Self Screening Questionnaire

Wild Roots COVID-19 Initial Self Screening Questionnaire

Please complete this form in the morning, BEFORE bringing your child to their first day.
Child's Full Name

First NameLast Name
Date

MonthDayYear
Date
If you answer “YES” to any of the questions, please DO NOT send your child to Wild Roots today.

If you experience any symptoms or answer “YES” to any of these questions, please immediately contact your health care professional for recommended next steps.

1) Has your child, or someone in your household, had any of the following symptoms in the last 14 days?*

Rows	Yes	No
Cough (new, not related to allergies)
Shortness of breath of difficulty breathing (new, not related to ongoing medical condition.)

OR at least TWO of the following symptoms in the last 14 days:*

Rows	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come to Wild Roots You should:
- Self-quarantine for at least 10 days from the date on which any of the above symptoms were first experienced; AND
- Wait until your child, or household member, has had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you:*

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come to Wild Roots. You should self quarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: