AYLA Health Check-In for 05/02/21
WELCOME! Please answer the following questions about your health today
STUDENT Name (first & last)
PARENT Name (first & last)
PARENT phone number
Are you experiencing any of the following symptoms. Check NO SYMPTOMS if none apply.
Elevated temperature (>100°F)
Shortness of breakth, difficulty breathing
Chills, muscle or body aches
congestion or runny nose
Nausea, vomiting, diarrhea or other gastrointestinal disease
New loss of taste or smell
NO SYMPTOMS TODAY
Do you have any other COVID -19 symptoms, positive test results or potential exposure to COVID?
NO COVID symptoms or potential exposure
Have you travelled outside the STATE in the last 14 days?
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This form was created inside of Punahou School.