Daily Health Screening Form-Leesburg Montessori Daily Health Screening Form-Leesburg Montessori Student Name*Classroom*Primary Classroom 1 - Mrs. Thompson/Ms AlexPrimary Classroom 2 - Ms MarikaPrimary Classroom 3 - Ms MariaPre-Primary Classroom 4 - Ms CrystalTemperature*Fever*YesNoCough*YesNoShortness of Breath / Difficulty Breathing*YesNoSore throat*YesNoRunny Nose / Nasal Congestion*YesNoFeeling unwell / Fatigued*YesNoNausea / Vomiting / Diarrhea*YesNoMuscle Aches*YesNoHeadache*YesNoConjunctivitis*YesNoFamily Health*Is anyone in your household sick or experiencing any of the above symptoms?YesNoTravel*Have you or anyone in your household travelled internationally, domestically, or to a known hotspot in the last 14 days?YesNoProximity to General Illness*Have you or your children attending the program had close unprotected* contact (face- to-face contact within 2 meters/6 feet) with someone who is ill with cough and/or fever?YesNoProximity to Confirmed Case*Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?YesNoParent Signature*Date* Date Format: MM slash DD slash YYYY
