Health Survey / Flu A, B , Covid19 or RSV

Health Survey / Flu A, B , Covid19 or RSV

Please fill out this health survey before returning to school
Student Name

First NameLast Name
Class or Grade Level
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contacts

Phone CallEmailPhone MessageOther
Birth Date

MonthDayYear
Age
Ex:23
Gender
Basic Symptoms Check
Do you have any of the following?

FeverRunny Nose / Stuffy NoseSore throatCoughingHaving gastrointestinal symptoms such as nausea, vomiting and diarrheaBody aches/pains or fatigue
If you are experiencing symptoms, have you taken an ATK test for the virus, and what was the result?

No, I haven’t done the test yetYes, I tested positive for Flu A, BYes, I tested positive for Covid19Yes, I tested positive for RSVYes, I tested negative for all viruses
If you are experiencing symptoms, have you been examined at a hospital and medical treatment, and do you have a medical certificate to confirm you sickness?

YesNo
If you are experiencing symptoms, are you currently undergoing treatment?

YesNo
If you are experiencing symptoms, since what date have you had them, or how many days have you been unwell?
Do you have any friends, people around you, or family members who are sick with influenza type a or B, COVID-19 or RSV?

YesNo
On a scale, how would you rate your risk of being infected?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
A Picture of your ATK result

Cancelof
Should be Empty:

Health Survey / Flu A, B , Covid19 or RSV

Basic Symptoms Check