Pre-Screening COVID-19 Questionnaire - Perfect Posture Pilates

Date *

First Name *

Last Name *

1. Have you or a member of your household traveled outside the U.S. in the past 14 days? *

Yes

2. Have you or a member of your household traveled elsewhere outside of New York State in the past 14 days? *

Yes

3. Have you or a member of your household traveled on a cruise ship in the past 14 days? *

Yes

4. Do you or a member of your household currently have or had COVID-19 in the last 14 days? *

Yes

5. Have you or a member of your household received a positive COVID-19 diagnostic test in the past 14 days? *

Yes

6. Have you or a member of your household had any of the following symptoms in the last 14 days: sore throat, cough, chills, body aches for unknown reasons, shorts of breath for unknown reasons, loss of smell, loss of taste, fever, temperature at or greater than 100 degrees F? *

Yes

7. To the best of your knowledge, have you been in close proximity to any individual who tested positive for COVID-19 in the last 14 days? *

Yes

If you answered yes to any of these questions, please provide additional details.

Consent

I hereby confirm that I have answered each question truthfully and to the best of my knowledge

Signature *

Clear