The Dance Element - Covid-19 Screening
* Required
Email address
*
Your email
Dancer's Name
*
Your answer
Date of Dance Class
*
MM
/
DD
/
YYYY
Parent/Guardian's Name
*
Your answer
Phone number
*
Your answer
Are you or your dancer currently experiencing any of the following symptoms?
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Fever (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher?
Chills
Cough that's new or worsening (Continuous, more than usual, not related to other known causes or conditions)
Barking cough, making a whistling noise when breathing (Croup, not related to other known causes or conditions)
Shortness of breath (Not related to other known causes or conditions - ex. asthma)
Sore throat (Not related to other known causes or conditions - ex. seasonal allergies, acid reflux)
Difficulty swallowing (Painful swallowing, not related to other known causes or conditions)
Runny nose ((Not related to other known causes or conditions - ex. seasonal allergies, being outside in cold weather)
Stuffy or congested nose (Not related to other known causes or conditions - ex. seasonal allergies)
Decrease or loss of taste or smell
Pink eye (Conjunctivitis, Not related to other known causes or conditions - ex. reoccurring styes)
Headache that's unusual or long lasting (Not related to other known causes or conditions - ex chronic migraines)
Digestive issues like nausea/vomiting, diarrhea, stomach pain)
Muscle Aches that are unusual or long lasting (Not related to other known causes or conditions)
Extreme tiredness that is unusual (Fatigue, lack of energy, not related to other known causes or conditions)
Sluggishness or lack of appetite
None of the above
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