C19 Screening Questions

COVID-19 Self Screening Questions

Please complete this form for your family who will be part of the photo session.
Family Name *
You must be able to answer “NO” for each member of your household to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT come to or enter Donna Frazier Photography Studio. Your session will be rescheduled until everyone is symptom free.

If you experience any symptoms or answer “YES” to any of these questions, you should immediately contact your health care professional for recommended next steps.

Temperatures WILL be take before admittance to studio and at location.

1) Are any members of your household experiencing any of the following symtoms now or within the past 48 hours? *

Yes

Fever (usually 100.4 F or higher)

Chills

Repeated shaking with chills

Cough (new or worsening of exisiting cough)

Shortness of breath or any difficulty breathing

Muscle pain

Headache

Sore throat

New loss of taste or smell

GI upset or diarrhea

Any other flu-like symptoms

If you answered “Yes” to any part of question one for any member of your household, please DO NOT come to the studio or location. Your entire household 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)

2) In the last 14 days has any member of your household: *

Yes

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 for any member of your household, please DO NOT come into the studio or location. Your entire household should self quarantine for at least 14 days.

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

Month Day Year
Date
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COVID-19 Self Screening Questions