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Pre-Screening Wellness Check
This is required every time you visit Groove Barre. For the safety of our staff and other clients, please answer the following questions honestly:
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First and Last Name
*
Your answer
Date of the visit you are completing this form for - Please note this assessment should be completed within 24 hours of your class at Groove Barre
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MM
/
DD
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YYYY
Have you experienced any of the following symptoms within the last 14 days? (Check all that apply)
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Fever or feeling feverish
Shortness of breath
Flu like symptoms that include, but not limited to, fatigue, nausea, diarrhea, chills, muscle pains, headaches, sore throat, loss of taste or smell, rash
None of the above
Required
Have you been diagnosed or suspected of having COVID-19 ?
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Yes
No
If yes, when?
Your answer
Have you been tested for COVID -19 in the last 14 days? If yes, regardless of result, please do NOT visit the studio
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Yes
No
If tested, did you test negative or positive?
Negative
Positive
Clear selection
Are any of your family members or close contacts currently sick or experiencing flu-like symptoms?
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Yes
No
Have any of your family members or close contacts been diagnosed with COVID-19?
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Yes
No
If yes, when?
Your answer
Have you recently travelled, domestically or internationally?
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Yes
No
If yes, when?
Your answer
Have any of your family members recently travelled, domestically or internationally?
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Yes
No
If yes, when?
Your answer
By checking this box, I acknowledge, know and understand that although all best efforts to clean and sanitize are made by Groove Barre, the risk of contracting an illness, including but not limited to COVID-19, exists. I understand the risks and freely and voluntarily accept and assume all such risks, and take full responsibility for my own actions, safety and welfare, and accept that Groove Barre does not take responsibility if I contract any such illness.
*
I agree
Required
By checking this box, I acknowledge that I do not have any medical condition(s), including but not limited to symptoms or a diagnosis of COVID-19, that would result in illness to the Client or anyone else, as a result of the my attendance to the premises of Groove Barre. If I am aware of any such medical condition(s) or symptoms, it will be my sole responsibility to abstain from attending any appointments made at the premises of Groove Barre.
*
I agree
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