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Pupils Health Declaration Form
Pupils Health Declaration Form
MEMORIAL SCHOOL
YES NO YES NO
1. Fever 7. Runny nose ✔️
2.Dry cough 8. Tiredness ✔️
3.Body weakness 9. Sore Throat ✔️
4. Headache 10. Diarrhea ✔️
5.Loose Bowel Movement 11. Shortness of Breath
6. Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Places visited within the past (2) weeks: _________________________________________
YES NO YES NO
1. Fever 7. Runny nose
2.Dry cough 8. Tiredness
3.Body weakness 9. Sore Throat
4. Headache 10. Diarrhea
5.Loose Bowel Movement 11. Shortness of Breath
6. Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Places visited within the past (2) weeks: _________________________________________
YES NO YES NO
1. Fever 7. Runny nose
2.Dry cough 8. Tiredness
3.Body weakness 9. Sore Throat
4. Headache 10. Diarrhea
5.Loose Bowel Movement 11. Shortness of Breath
6. Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Places visited within the past (2) weeks: _________________________________________
YES NO YES NO
1. Fever 7. Runny nose
2.Dry cough 8. Tiredness
3.Body weakness 9. Sore Throat
4. Headache 10. Diarrhea
5.Loose Bowel Movement 11. Shortness of Breath
6. Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Places visited within the past (2) weeks: _________________________________________