St-Theresa – Student Temp Check

Parent Name

Parent E-mail

Parent Phone Number

Cell Phone / Teléfono móvil

Student Name

First Name & Last Name / Nombre y Apellido

Current Date and Time: Jan-25-2021 20:49:01

Temp Check Date

Temp Check Time

Is Temp 100°F or higher?

Yes No

COVID-19 Symptoms

In evaluating whether an individual has symptoms consistent with COVID-19, consider the following
question:

Have they recently begun experiencing any of the following in a way that is not normal for them?

Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit
• Loss of taste or smell
• Cough
• Difficulty breathing
• Shortness of breath
• Fatigue
• Headache
• Chills
• Sore throat
• Congestion or runny nose
• Shaking or exaggerated shivering
• Significant muscle pain or ache
• Diarrhea
• Nausea or vomiting

Yes No

COVID-19 Symptoms

In evaluating whether an individual has symptoms consistent with COVID-19, consider the following question: Have they recently begun experiencing any of the following in a way that is not normal for them?

In evaluating whether an individual has symptoms consistent with COVID-19, consider the following
question:

Have they recently begun experiencing any of the following in a way that is not normal for them?