Health Questionnaire

HPP Health Screening Questionnaire

Please print the name of every family member entering the pool below.

Date of your swim ___________________________

Time slot of your swim ________________________

 Please circle the answer the following questions:

	Does anyone in your house have a cough and/or sore throat?	Yes	No
	Has anyone in your house had a fever in the last 72 hours (3 days) or the sense of having a fever?	Yes	No
	Do you have any shortness of breath or is it hard for you to breathe?  Are you experiencing chills or muscle aches not attributed to exercise?	Yes	No
	Have you had any contact with someone known to have, or be under investigation for coronavirus, in the last 14 days (2 weeks)?	Yes	No

Please sign and date below if you believe that you have answered these questions honestly and to the best of your knowledge.  If swimmer is under the age of 18, parent/guardian must also sign the document.

Signature of Swimmers            Signature of Parent/Guardian             Date

Please fill out and bring this document with you to the pool.

Thank you!

Stay Happy, Health, & Safe!