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Student Symptom Referral
High School
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Student Name
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Teacher Name
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Time
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Time
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Date
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This student is being referred due to the following reasons/symptoms:
Possible Fever
New or persistent cough
Loss of taste or smell
Chills
Congestion/runny nose
Sore throat
Headache
Nausea/vomiting
Diarrhea
Muscle Pain
Fatigue
Injury
Other
If injury or other, please explain
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