COVID-19 Screening Questionnaire Please complete this COVID-19 Screening Form. Date* MM slash DD slash YYYY First Name:*Last Name:*Street Address:City:State /Province/Region:Zip/Postal Code:Phone:*Email:* A copy of this form will be sent to this email address.Please check all that apply: You had a close contact with confirmed or suspected COVID-19 cases within the past 14 days You traveled out of the US and/or any state that requires quarantine. For a Current list of US States under advisory in the past 14 days You had a positive COVID-19 test within the past 14 days You have pending COVID-19 test results You have a fever above 100.0F Within the past 14 days you had the following COVID-19 symptoms (Check all that apply): New Unexplained Cough New Unexplained Shortness of Breath New Unexplained Fever New Unexplained Chills New Unexplained Muscle Pain New Unexplained Sore Throat Please remember to stay SAFE- Wear a facial mask, please social distance and wash your hands for 20 seconds before and after your workout program! Signature:Captcha Δ
