COVID-19 Assessment

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COVID-19 Assessment

It is mandatory that everyone who enters the Vancouver Mind-Body Centre studio complete this screening PRIOR to entering the space. This checklist may be updated as the situation progresses over the next weeks and months.

Please fill out this form on the DAY of each class, at least 1 hour before EACH class. The submission time will be noted and your instructor will confirm your submission before training.

Email *

Full name *

Date of class *

YYYY

Time of class *

Time

Name of class

Aikido

Conditioning & Recovery

Core Strength

Fitness Kickboxing

Karate

Kettlebells

Strength & Agility

Clear selection

Are you Experiencing any of these symptoms? *

Fever greater than 38C or chills

Stuffy and or runny nose

Sore throat or difficulty swallowing

Sneezing

Coughing

Headache

Loss of appetite

Shortness of breath

Loss of sense of smell

Fatigue related to illness

Muscle aches related to illness

Required

Have you or someone in your household travelled outside of Canada in the last 14 days? *

Yes

Have you, or has anyone in your household been in contact in the last 14 days with someone who is being investigated or who has a confirmed case of COVID-19? *

Yes

Are you currently being investigated as a suspect case of COVID-19? *

Yes

Have you tested positive for COVID-19 within the last 10 days? *

Yes

Submit

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