COVID-19 Self Screening Questionnaire

You must answer “NO” to all the questions regarding symptoms in this questionnaire in order to enter our physical location. If you answer “YES” to any of the symptom questions, please DO NOT come to the building.

If you experience any symptoms or answer “YES” to any of these symptom questions, you must immediately contact your health care professional for recommended next steps AND notify Bonnie at 541-231-6040. At any point the instructor or Bonnie may decide that it is safest to transfer your lesson into a Zoom meeting.

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:*

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come to Maestro Music for your lesson. You should:

Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
Improved respiratory symptoms (no cough, shortness of breath) AND
Contact your primary care physician.

2) In the last 14 days have you:*

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come to Maestro Music in person. You should self quarantine for at least 14 days.

3) Do you agree:*

	Yes	No
to voluntarily and knowingly assumed the risk of exposure by allowing yourself or your child to come to the studio?

I certify to the best of my knowledge; this information is accurate.

Signature*

Name*

First NameLast Name

Student Name (if applicable)

Date*

Date