Covid 19 Screening Questionnaire

Name *

First Name

Last Name

Phone *

(###)

###

####

Scheduled Lesson Date *

MM

DD

YYYY

Have you had the Covid 19 Vaccination? *

Yes

No

Have you been diagnosed with Covid 19 in the past 30 days? *

Yes

No

Do you currently have a fever? *

Yes

No

Do you have any cold or flu like symptoms today or within the last 14 days including fever, cough, sore throat, chills, runny nose, shortness of breath, or any respiratory issues. *

Please check YES if you currently have or had EVEN ONE of these symptoms now or in the last 14 days.

Yes

No

Have you been in contact with or cared for anyone with suspected or confirmed cases of COVID 19 in the past 14 days? *

Yes

NO

Have you traveled Domestically or Internationally within the last 4 weeks? *

Yes

No