COVID-19 Screening Questionnaire
The safety of our students is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our Center, we are asking everyone to complete this questionnaire prior to entering the facility.


Safety instructions:
1. All students are required to wear a face mask or face covering when inside the facility & during class.
2. Temperature will be taken at the door, if you are not feeling well, please stay home.
3. Each student will be asked to use hand sanitizer prior to class.
4. Students will need to bring a water bottle to class. Our water dispenser will be temporarily unavailable.
5. We are continue practicing social distance in the Center.
6. No shoes in the training area.
7. Do NOT enter the building before your scheduled classes.


Address: 21732 Provincial Blvd. #100 Katy, TX 77450
Phone: 832-363-7994


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Email *
Student Last Name: *
Student First Name: *
Age: *
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? *
Yes
No
Fever (100.4° F/37.8° C or greater)
Cough
Shortness of breath or difficulty breathing
Sore throat
New loss of taste or smell
Chills
Head or muscle aches
Nausea, diarrhea, vomiting
In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *
Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms? *
In the past 14 days, have you been traveled outside of the United States or Texas? *
In the past 14 days, have you been in close proximity to anyone who has been traveled outside of the United States or Texas? *
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