Student COVID-19 Self Screening Questionnaire

Student COVID-19 Self Screening Questionnaire
You must answer “NO” to all the questions in this questionnaire in order to enter this studio. If you answer “YES” to any of the questions, please DO NOT enter the studio.

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
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

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?
Travelled internationally or taken a cruise?

Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Type a question
Should be Empty: