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?

Rows	Yes	No
Cough
Shortness of breath of difficulty breathing

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

Rows	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:

Rows	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
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type a question
Should be Empty: