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 NONE of the SITUATIONS or CONDITIONS listed. Within the past 14 days you had the following COVID-19 symptoms (please 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 NO SYMPTOMS as LISTED Please remember to stay SAFE.- Wear a facial mask, please remember to social distance and wash your hands for 20 seconds before and after your workout program!Signature:Captcha Δ
