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*

(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
Difficulty breathing*

(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
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
Feeling unwell, muscle aches or tired*

(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
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
Sore throat or pain swallowing*

(painful swallowing or difficulty swallowing)

Not related to other known causes or conditions (e.g., post nasal drip, gastroesophageal reflux)
- 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
2. Is there a child or sibling in your household who has one or more of the above symptoms?*
- YES
- NO
3. Has the student travelled outside of Canada in the past 14 days?*
- YES
- NO
4. Has the student been notified as a close contact of someone with COVID-19?*
- YES
- NO
5. Has the student been told to stay home and self-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
Date Format: MM slash DD slash YYYY

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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.

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