Student Health Questionnaire
Coronavirus Disease 2019 (COVID-19) has been reported in every state and in countries around the world. COVID-19 can cause respiratory or gastrointestinal illness.
In order to protect you and others, we are asking everyone about symptoms and exposure to COVID-19 prior to entering the gym. Your health is our priority, please answer these questions so that we can keep everyone safe within our facility.
Please do not enter gym until you have response to the questionnaire and your entry has been approved.
Name of Student
Name of Parent
Cosmic Bear / Thunder Cats
Day of the Week
Do you have a fever?
Do you currently have a cough or shortness of breath?
Are you experiencing any other NEW symptoms listed below which may be associated with COVID-19? Please select all that apply.
None of the below
Chills or shaking
Muscle aches and pains
New loss of taste or smell
Vomiting or diarrhea
In the past 2 weeks, have you (or anyone in your household) traveled to an area with an increase in COVID-19 cases?
In the past 2 weeks, have you (or anyone in your household) been diagnosed, tested or quarantined under a doctor's orders for COVID-19? Please select all that apply:
None of the below
A doctor ordered me to quarentine for possible COVID-19.
I was tested and am waiting for my results.
I tested positive.
I tested negative.
Someone at home has fever, cough, or difficulty breathing but has not been diagnosed.
Someone in my home tested positive.
Someone in my home tested negative.
In the past 2 weeks, have you been in contact with someone who has been diagnosed, tested or quarantined under a doctor's orders for COVID-19?
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