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Cardinal Check

St. Raymond School

Cardinal Check

COVID-19 Health Screening Form

Parent Name:
Within the last 10 days have you or your child(ren) been diagnosed with COVID-19 or had a test confirming you or your child(ren) have the virus?

Within the past 14 days, did you live in the same household as, or did you have close contact with someone who tested positive for COVID-19 and/or someone who has been in isolation for COVID-19? Close contact is less than 6 feet for 15 minutes or more regardless of whether masks are worn or not.

Have you or your child(ren) had any new symptoms excluding pre-existing/longstanding symptoms and/or symptoms that can be attributed to a diagnosis other than COVID-19 since the last symptom check?

In the absence of a more likely diagnosis:

  • New loss of taste or smell (e.g. new olfactory or taste disorder)
  • Painful purple or lesions on the feet or swelling of the toes (COVID Toes)
  • Pneumonia (on clinical exam or imaging)
  • Fever (temperature ≥ 100.4℉/38℃ or subjective fever)
  • Cough (new or change in baseline)
  • Shortness of breath or difficulty breathing (new or change in baseline)
  • Chills
  • Repeated shaking with chills (rigors)
  • Chest pain with deep breathing
  • Sore throat
  • Hoarseness
  • Runny nose or congestion
  • Muscle pain (myalgia)
  • Malaise or fatigue
  • Abdominal pain
  • Loss of appetite
  • Nausea
  • Vomiting
  • Diarrhea
  • Headache
  • Altered mental status (e.g. confusion)
  • Conjunctivitis or “pink eye”
  • Rash