Health Declaration Form - Splash Island

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1. Do you have cough? *

Yes No

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2. Do you have cold? *

Yes No

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3. Do you have sore throat? *

Yes No

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4. Are you having diarrhea? *

Yes No

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5. Are you experiencing body aches? *

Yes No

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6. Do you have headache? *

Yes No

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7. Are you having difficulty breathing? *

Yes No

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8. Are you experiencing fatigue? *

Yes No

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9. Have you traveled recently during the past 14 days? *

Yes No

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10. Do you have a travel history to a COVID-19 infected area? *

Yes No

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11. Do you have direct contact or is taking care of a positive COVID-19 patient? *

Yes No

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12. What line of work are you in? *

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