COVID-19 Screening | www.ilmstutor.com

Covid-19 Health Declaration

¿Cómo te sientes hoy?

Padres, por favor llenen este formulario para su hijo antes de enviarlo al centro.

Tutores, por favor llenen este formulario antes de venir al centro para sus sesiones.

Si ha marcado alguna de las respuestas, comuníquese con nuestra oficina y no venga al centro. Comuníquese con su profesional de la salud para obtener más ayuda.

Name

Student, Parent or Tutor

Phone number

Are you experiencing any of the following conditions, not caused by a pre-existing medical condition: Fever or chills, headache, bodyache, fatigue, nausea, vomitting, diarrhea, shortness of breath, cough? Check box if yes.

Are you on any fever reducing medications to suppress any of the symptoms listed above? Check box if yes.

Have you tested positive for COVID-19 in the last 10-14 days? Check box if yes.

Have you been in close contact with a COVID-19 positive patient or someone with COVID like symptoms? Check box if yes.

In the last 14 days, have you been advised by a health care professional to self-isolate or self-quarantine because of concerns of COVID infection? Check box if yes.

Are you/your child vaccinated? *(optional)

I declare that the info I’ve provided is accurate & complete

Signature

Date

I accept terms & conditions

Thanks for submitting. We will contact you if needed.