Hard work is child’s play

Community Health Screening Form

Full Name of Person Screened

Classroom

Temperature (Farenheit)

Is the person screened experiencing a temperature of or over 100.4°F (without temperature lowering medications); or any of the following symptoms if the symptom is of greater intensity or frequency than what is normally experienced:

Yes

Cough
Shortness of breath or difficulty breathing
Fever or chills
Fatigue
Repeated shaking with chills
Muscle or body aches
Headache
Sore throat
Loss of taste or smell
Diarrhea
Congestion or abnormally runny nose
Nausea or vomiting

In the previous 5 days has anyone in the household been notified of a positive off-campus exposure to someone confirmed to have COVID-19? (If your child has tested positive for Covid-19, has completed their quarantine, and has been cleared to return by Elizabeth Marcilla, our Covid Officer, please select 'No'.

Yes

Has any medication been taken for the purpose of symptom reduction in the last 24 hours?

Yes

Signature

Escuela del Sol Montessori • 1114 Seventh Street NW, Albuquerque, NM 87102 • 505-242-3033 • 800-317-4752 (fax)