COVID-19 Health Questionnaire
Please fill out and return prior to your session
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Email *
Name and Date of Session: *
By the time of your session will you have completed a CDC approved COVID-19 vaccination? *
Have you experienced a fever of 100.4 F or higher, a new cough, loss of taste or smell, or shortness of breath in the last 10 days? *
In the past 10 days have you tested positive for COVID-19? *
Within the past 10 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have a laboratory-confirmed COVID-19 case or with anyone who has any symptoms consistent with COVID-19? *
Do you agree to alert the studio (soundBOX:LA) if you test positive for Covid-19 before, during or within 14 days of your session? *
Have you been, or are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? *
Have you experienced any of the following symptoms in the past 48 hours:                                                                 • fever or chills• cough• shortness of breath or difficulty breathing• fatigue• muscle or body aches• headache• new loss of taste or smell• sore throat• congestion or runny nose• nausea or vomiting• diarrhea *
If you answered yes to the previous question, please explain.
Are you currently waiting results of a COVID-19 test? *
Please type your name to acknowledge that you have answered these questions to the best of your ability. *
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