Student Health Check Form
Name (First & Last)
In the last 24 hrs have you been in contact with anyone with a known case of COVID-19 virus?
Have you traveled out of state or county within the last 24 hrs?
Please record your temperature
Do you have any of these symptoms that are not caused by another condition?
Any symptoms have been cleared by a health care provider
Fever or chills
Shortness of breath or difficulty breathing
Muscle or body aches
Unusual or new headache in last 24 hrs
Recent loss of taste or smell
Tingling or numbness
Nausea or vomiting
If you answered yes to any symptoms, have a temperature of over 100 degrees F, or if exposed to a COVID positive person, please stay home. Thank you for keeping our community safe.
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This form was created inside of Sebastopol Charter.