2021 Camper Health Screening Form

CONTACT HISTORY FIRST NAME Yes No Fever (above 100.4 F) Cough Shortness of breath New loss of taste or smell Body aches Diarrhea Lice Vomiting Itchy / Red eyes Headache Sore throat No symptoms STAFF NOTES CAMPER NAME: SYMPTOMS IN THE LAST TWO WEEKS - Check all that apply to the camper: CAMPER HEALTH SCREENING LAST NAME The camper has been diagnosed with COVID-19 in the last 90 days If yes, date of positive test result: ________________ The camper has been in contact with someone who tested positive for COVID-19 in the last 14 days F TEMPERATURE AT CHECK IN: Fever (above 100.4 F) Cough Shortness of breath New loss of taste or smell Body aches Diarrhea Lice Vomiting Itchy / Red eyes Headache Sore throat No symptoms CONTACT HISTORY CAMPER NAME: F LAST NAME TEMPERATURE AT CHECK IN: FIRST NAME The camper has been diagnosed with COVID-19 in the last 90 days If yes, date of positive test result: ________________ The camper has been in contact with someone who tested positive for COVID-19 in the last 14 days STAFF NOTES Yes No SYMPTOMS IN THE LAST TWO WEEKS - Check all that apply to the camper: CAMPER HEALTH SCREENING