Play Make-Believe

Name

Date

Event

Are you or anyone in your household currently waiting on the results of a COVID test?

Yes

No

In the last 14 days have you been in contact with someone who has tested positive for Coronavirus?

Yes

No

In the last 14 days have you experienced a new or continuous cough/ shortness of breath that cannot be attributed to another health condition?

Yes

No

In the last 14 days have you experienced a fever?

Yes

No

In the last 14 days have you noticed a change in your sense of taste or smell (Anosmia)?

Yes

No

In the last 14 days have you partaken in international travel to countries not on the ‘SAFE’ list under new quarantine travel rules?

Yes

No

Covid 19 Health Declaration