Swim School - COVID-19 SYMPTOMS SCREENING QUESTIONNAIRE
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Name *
Surname *
Child Name *
Temperature reading (PARENT)
Temperature reading (CHILD)
Red eyes? *
SIGNS (EXAMINATION)
Do you or your child have a cough? *
Do you or your child have shortness of breath? *
Do you or your child have sore throat? *
Do or your child have a recent loss of taste? *
Do or your child have a recent loss of smell? *
Are you or your child nauseous? *
Are you or your child vomiting? *
Do you or your child have diarrhoea? *
Are you or your child experiencing other flu-like symptoms (weakness or tiredness)? *
Do you or your child experience body pain/body aches? *
EXPOSURE WITHIN THE PAST 14 DAYS
Have you or your child had contact with a confirmed COVID-19 positive person? *
Have you or your child had contact with a probable COVID- 19 positive person? *
Have you or your child traveled to identified hotspot areas with local transmission of SARS-CoV-2: (NB. Affected countries/ cities/ districts will change with time, consult the NICD website for current updates) *
Have you or your child traveled to high risk areas? *
Did you or your child sleep in a hotel or lodge/guesthouse? *
Were you or your child ever admitted to the hospital or visited doctor’s rooms since lockdown started? *
Have you or your child visited or currently live in a high COVID-19 prevalence area? *
Comments?
I confirm the above information is correct and was completed by me with no interference or influence by any third party. *
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