Equestrian Park Participant Health Questionnaire
If you are experiencing symptoms related to Covid-19 we ask you to; reconsider your attendance to your scheduled event, distance yourself from other attendees and facility employees, seek proper medical attention, and visit our facility again once cleared by a medical provider or you are symptom free for 48hrs.
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Name *
Phone #: *
Email: *
Event Attending: *
ARE YOU EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS: Fever (>100.4 F), Chills, or Sweating.• Shortness of Breath or Difficulty Breathing• Cough• Vomiting or Diarrhea• Muscle Pain or Aching Throughout the Body• Sore Throat• Sudden or New Loss of Taste or Smell *
Required
Date: *
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ARE YOU TAKING ANY MEDICATIONS FOR THESE SYMPTOMS? *
IS SOMEONE YOU LIVE WITH EXPERIENCING ANY OF THESE SYMPTOMS? *
IS SOMEONE YOU HAVE COME INTO CONTACT WITH IN THE LAST TWO WEEKS EXPERIENCING ANY OF THESE SYMPTOMS? *
ARE YOU CURRENTLY UNDER THE ADVISEMENT TO SELF ISOLATE PENDING RESULTS OF A COVID-19 TEST? *
ARE YOU CURRENTLY UNDER ADVISEMENT TO SELF ISOLATE AS A RESULT OF A POSITIVE COVID-19 TEST? *
IS SOMEONE IN YOUR HOUSEHOLD CURRENTLY UNDER THE ADVISEMENT TOSELF ISOLATE AS A RESULT OF A POSITIVE COVID-19 TEST? *
BY CHECKING AGREE BELOW, I AM CERTIFYING ALL INFORMATION ON THIS FORM TO BE ACCURATE TO THE BEST OF MY KNOWLEDGE: *
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