1st Visit May 24th-30th PURPLE DRAGON KITSILANO COVID-19 Student Weekly Assessment Question Title * 1. Name(In-addition family or siblings attending) Question Title * 2. This week's class day attending: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Question Title * 3. Are you experiencing ANY cold, flu, or COVID symptoms? Yes No Question Title * 4. Are you experiencing any of the specific symptoms below? Cough Fever Difficulty Breathing or shortness of breath Loss of taste or smell Sore throat Runny nose Extreme headache or muscle ache NONE Question Title * 5. Have you traveled outside Canada or another province in the last 2 weeks? Yes No Question Title * 6. Have you had close contact with a confirmed covid case in the past 2 weeks? Yes No Question Title * 7. If your answer to #6 was Yes, have you been tested and received a negative result? Yes No NA SUBMIT - If you answered YES to any of the above questions, please reschedule your session