Spooky Shuffle Wellness Verification

COVID-19 Pre-Check

To protect the health of our staff and community, the Community Park District & Strive 4 Fitness require that all participants out this questionnaire before arriving to the Spooky Shuffle 5K or Sprint. Runners may not be admitted to the event without a completed wellness log.

Question Title

* 1. Runner's Information

Last Name

First Name

Full Name of Adult Completing the Survey (If different from participant)

Phone Number

Question Title

* 2. Do you exhibit any of the following symptoms?

	Yes	No
Cough	Cough Yes	Cough No
Sore Throat	Sore Throat Yes	Sore Throat No
Runny Nose	Runny Nose Yes	Runny Nose No
Congested Nose	Congested Nose Yes	Congested Nose No
Shortness of Breath	Shortness of Breath Yes	Shortness of Breath No
Chills	Chills Yes	Chills No
Unexplained Muscle Aches	Unexplained Muscle Aches Yes	Unexplained Muscle Aches No
Headache	Headache Yes	Headache No
Unexplained Fatigue	Unexplained Fatigue Yes	Unexplained Fatigue No
Abdominal Pain	Abdominal Pain Yes	Abdominal Pain No
Nausea or Vomiting	Nausea or Vomiting Yes	Nausea or Vomiting No
Diarrhea	Diarrhea Yes	Diarrhea No
Loss of Smell or Taste	Loss of Smell or Taste Yes	Loss of Smell or Taste No

Question Title

* 3. Please enter your temperature

Question Title

* 4. What time did you take your temperature

Date / Time

Date

Time

AM/PM