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Montessori School of Leesburg & Purcellville

Daily Health Screening Form-Purcellville Montessori

Student Name*
Classroom*
Temperature*
Fever*
- Yes
- No
Cough*
- Yes
- No
Shortness of Breath / Difficulty Breathing*
- Yes
- No
Sore throat*
- Yes
- No
Runny Nose / Nasal Congestion*
- Yes
- No
Feeling unwell / Fatigued*
- Yes
- No
Nausea / Vomiting / Diarrhea*
- Yes
- No
Muscle Aches*
- Yes
- No
Headache*
- Yes
- No
Conjunctivitis*
- Yes
- No
Family Health*
- Yes
- No
Is anyone in your household sick or experiencing any of the above symptoms?
Travel*
- Yes
- No
Have you or anyone in your household travelled internationally, domestically, or to a known hotspot in the last 14 days?
Proximity to General Illness*
- Yes
- No
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?
Proximity to Confirmed Case*
- Yes
- No
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?
Parent Signature*
Date*
Date Format: MM slash DD slash YYYY

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