COVID-19 Screening Form

Date*

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 above

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

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!

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