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Mang'Oh Yoga Pre-Class Screening
Please fill this form out before arriving for your mang'Oh yoga class. Have questions? Feel free to call us at 212.661.6655 or email
stephanie@mangohstudio.com
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* Indicates required question
Name (First and Last)
*
Your answer
*
MM
/
DD
/
YYYY
Have you tested positive for COVID -19 in the last 14 days?
*
Yes
No
Required
If yes, on what date did you receive the results?
MM
/
DD
/
YYYY
Do you have any of the following respiratory symptoms?
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Fever
Sore Throat
Cough
Shortness of breath
Lost sense of smell or taste
No symptoms
Required
Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
*
Yes
No
Have you been in contact with someone who has tested positive for or has had symptoms of COVID-19 in the last 14 days?
*
Yes
No
Have you traveled outside the tri-state area in the past 14 days?
*
Yes
No
I certify that the above information is true to the best of my ability. Please add typed signature below.
*
Your answer
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