Student Daily Wellness Assessment Form

Do you have any of the following symptoms in the last 14 days?

Rows	No, I don't have this symptom	Yes, I have this symptom
Temperature (100.4F or higher)	1	2
Nasal Congestion	3	4
Runny nose	5	6
Loss of taste	7	8
Loss of smell	9	10
Difficulty of breathing	11	12
Cough	13	14
Sore throat	15	16
Headache	17	18
Body weakness	19	20
Diarrhea	21	22

If the student answered yes to any of the symptoms in the table above, the student must stay home until the symptom is gone for a day.
It is also recommended to have a COVID test in order to make sure what is the root cause of the symptom.
Were you in close contact with anyone who is positive for COVID-19?
Did you traveled anywhere from the last 7 days?
Do you have a family or household member who has symptoms of COVID-19?
Do you have a family or household member who is positive for COVID-19?
By signing below, I confirm that the information I entered in this document regarding my health condition is accurate and true.
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