COVID-19 Screen | Shugyō Karate Dōjō

Covid-19 Health Declaration

How is the participant feeling?

First Name of Participant(s)

Last Name of Participant(s)

Participant is not experiencing a fever

Participant is not experiencing any other related symptoms: chills, cough or barking cough, shortness of breath, decrease or loss of either smell or taste, sore throat or difficulty swallowing, extreme tiredness, muscle aches, runny or stuffy nose unsual headache, vomitting or diarhea, or falling down.

Participant hasn't been in close contact with a Covid-19 patient in the last 5 days

Initials

Date

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

I comfirm the participant has not been instructucted by a doctor, nurse, or other health care provider that said participant should be isolated, and that no one that the participant lives with is currently waiting on the results of a COVID-19 test after experiencing symptoms.

Thanks for submitting!