Participant COVID-19 Self Screening Questionnaire

Participant COVID-19 Self Screening Questionnaire

Pure Sk8
You must answer “NO” to all the questions in this questionnaire in order to participate. If you answer “YES” to any of the questions, please DO NOT come to the session.

If you answered “yes” to any of these questions please do not participate. Go home and use the AHS Online Assessment Tool to determine if testing is recommended.

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:*

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

2) In the last 14 days have you:*

	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 the ice session.

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

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: