COVID PRE-CLASS SCREENING

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This form should be completed before every visit to our studio

Name *

Email *

Are you fully vaccinated against COVID-19? *

Yes

In the last five days have you experienced any of the following symptoms? Fever/chills, cough/barking cough, shortness of breath, decrease or loss of sense of taste/smell, muscles aches/joint pain, extreme tiredness, sore throat, runny or stuffed/congested nose, headache, nausea, vomiting, and/or diarrhea *

Yes

Have you travelled outside of Canada in the last 14 days and been told to quarantine? *

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

Yes

In the last 5 days, have you tested positive for COVID-19? *

Yes

Do any of the following apply? (Check all that apply)

You live with someone who is currently isolating because of a positive COVID-19 test

You live with someone who is currently isolating because of COVID-19 symptoms

You live with someone who is waiting for COVID-19 test results

In the past 5 days, you have been identified as a “close contact” of someone who currently has COVID-19 or has symptoms of COVID-19

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