Covid Questionnaire

Health Questionnaire
Due to the recent outbreak of COVID-19 Simply Pilates Inc. is taking extra precations to ensure the safety of all clients. By completeing the following form you are acknowleding that you will be truthful in answering the following questions to ensure the safty and well being of all staff and clients in the studio.
Name

First Name Last Name
Date

Month Day Year
Date
COVID-19 affects different people in different ways. Infected individuals have had a wide range of symptoms reported, from mild to severe. The most common symtoms include but are not limited to:
- fever
- cough
- shortness of breath
- fatigue
- muscle aches
- loss of taste or smell
- sore throat
- nasal congestion
- GI upset
Are you currently experiencing any of the symptoms associated with COVID-!9 as listed above?

YES NO
Have you or any household members experienced any of the symptoms listed above in the last 14 days?

YES NO
Have you or any household members tested positive for COVID-19 within the last 14 days?

YES NO
Have you or any household members traveled out of New York in the last 14 days?

YES NO
If you or any household members traveled out of New York in the last 14 days, where did you travel to?
By signing below, you are acknowledging that you have read the policy changes and protocols for attending a session/class at the studio. (They can be found on the website simplypilates.net) and will comply with said policies/procedures.

By signing below, you are acknowledging that Simply Pilates Inc. cannot be held liable for any exposure to COVID-19 caused by misinformation on this form or the heath history provided by each client.

By signing this form, I acknowledge that I am aware of the risks involved and affirm that I have provided truthful and accurate information.
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Health Questionnaire