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6
Questions
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1
Your Name
*
This field is required.
First Name
Last Name
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2
Date and Time
*
This field is required.
Date
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Year
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Minutes
AM
PM
PM
AM
PM
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3
Have you experienced any of the following in the last 24 hours?
*
This field is required.
Do you have a
Fever
(temperature over 100.30F) without having taken any fever reducing medications? Do you have a
Loss of Smell or Taste?
Do you have a
Cough
? Do you have
Muscle Aches
? Do you have a
Sore Throat
? Do you have
Shortness of Breath
? Do you have
Chills
? Do you have a
Headache?
Have you experienced any gastrointestinal symptoms such as
nausea/vomiting, diarrhea, loss of appetite?
Have you, or anyone you have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19? Have you been asked to self-isolate or quarantine by a medical professional or a local public health official?
YES
NO
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4
Signature
*
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Clear
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5
Please Show the Trainer Your Phone:
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6
Please Show the Trainer Your Phone:
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