Curb Hair Studio Covid-19 Prescreen Questionnaire

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( ALL INFORMATION IS KEPT CONFIDENTIAL)

Email *

Name, Address, Phone number

• Do you feel like you have a fever, or have you checked your temperature to see if you have a fever (100ºF or higher)?

Yes

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Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?

yes

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Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?

Yes

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• Have you felt like you’ve had a fever in the past day?

Yes

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• Do you have a new or worsening cough?

Yes

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• Have you traveled within the past 14 days from or been with someone from a COVID-19 affected geographic area, including another country or state?

Yes

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Have you or anyone in your household traveled in the U.S. in the past 21 days?

Yes

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Are you or anyone in your household a health care provider or emergency responder?

Yes

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• Have you had close contact with a person diagnosed with or suspected of having COVID-19 in the past 14 days?

Yes

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• Have you received a positive test result for COVID-19?

Yes

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• Are you waiting to receive results of a COVID-19 test?

Yes

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