Avalon Montessori School

Health Screening Form

Avalon Children's Montessori School COVID Screening Questions

Please note you must do one submission for each Avalon Children's Montessori School student in your family.
Student Name*
Temperature*
Please take your child’s temperature and record the results here
1. Does your child have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.
Fever and/or chills*

(temperature of 37.8°C/100.0°F or greater)
- YES
- NO
Cough*

(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)
- YES
- NO
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)
- YES
- NO
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)
- YES
- NO
2. Does your child have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.
Sore throat*

(painful swallowing or difficulty swallowing)

Not related to other known causes or conditions (e.g., post nasal drip, gastroesophageal reflux)
- YES
- NO
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)
- YES
- NO
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)
- YES
- NO
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)
- YES
- NO
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)
- YES
- NO
3. Has your child travelled outside of Canada in the past 14 days?*
- YES
- NO
4. Has your child been identified as a close contact of someone who is confirmed as having COVID-19 by your local public health unit (or from the COVID Alert app if they have their own phone)?*
- YES
- NO
5. Has your child been directed by a health care provider including public health official to isolate?*
- YES
- NO
Who is dropping off your child today?*
Have you and / or anyone in your household traveled outside of Ontario in the last 14 days?*
- Yes
- No
Where did you/they go?*
Parent Signature*
Parent Name*
Parent Email*
Date

Avalon Montessori School|registrar@avalonmontessori.ca|416-690-7744|416-686-6621

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Avalon Montessori School

Avalon Children's Montessori School COVID Screening Questions

1. Does your child have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.

2. Does your child have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.

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