E.O. Smith Athletics - Wellness Self-Assessment
This form is designed for students to report their self screening for potential illness symptoms. *IF THE ANSWER IS "YES" TO ANY OF THE FOLLOWING QUESTIONS, STUDENTS SHOULD NOT ATTEND ACTIVITIES ON THAT DATE. STUDENTS WILL NEED TO REMAIN HOME FOR AND GAIN A DOCTORS NOTE TO RETURN TO ACTIVITY
First name *
Last name *
Sport *
Have you tested positive for COVID-19? *
If you tested positive, what was the date you tested positive? Did you isolate and self-quarantine for 14 days after?
For the following questions, please indicate whether you (the participant) have experienced any of the following within the past 14 days. If you answer YES to any of the items below, please stay home.
Have you traveled out of the country or to a state on the Governor’s Travel Advisory List? (https://portal.ct.gov/Coronavirus/travel) * *
Temperature is Over 100 degrees *
Fever or chills *
Cough *
Nasal Congestion or Runny Nose *
Sore Throat *
Shortness of Breath or Difficulty Breathing *
Dairrhea *
Nausea or Vomiting *
Fatigue *
Headache *
Muscle or Body Aches *
Loss of Taste or Smell *
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