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Your Name (must be legal parent/guardian of participant)
Participant Name
Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higherCough - (more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing). Not related to other known causes or conditions (e.g., asthma, reactive airway)Shortness of breath - (dyspnea, out of breath, unable to breathe deeply, wheeze, that is worse than usual if chronically short of breath). Not related to other known causes or conditions (e.g., asthma)Decrease or loss of smell or taste - (new olfactory or taste disorder). Not related to other known causes or conditions (e.g., nasal polyps, allergies, neurological disorders)None of the above
Sore throat - (painful swallowing or difficulty swallowing). Not related to other known causes or conditions (e.g., post nasal drip, gastroesophageal reflux)Stuffy nose and/or runny nose - (nasal congestion and/or rhinorrhea). Not related to other known causes or conditions (e.g., seasonal allergies, returning inside from the cold, chronic sinusitis unchanged from baseline, reactive airways)Headache that is new and persistent, unusual, unexplained, or long-lasting Not related to other known causes or conditions (e.g., tension-type headaches, chronic migraines)Nausea, vomiting and/or diarrhea - Not related to other known causes or conditions (e.g. transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effect of medication)Fatigue, lethargy, muscle aches or malaise - (general feeling of being unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained. Not related to other known causes or conditions (e.g., depression, insomnia, thyroid dysfunction, anemia)None of the above
YesNo
If you answered “YES” to any of the symptoms included under question 1:
If you answered “YES” to only one of the symptoms included under question 2:
If you answered “YES” to two or more of the symptoms included under question 2:
If you answered "YES" to question 3, 4 or 5: