COVID-19 Screening Form | nextlevelpilates-net

Next Level Pilates COVID-19 Screening Questionnaire

To ensure Next Level Pilates remains a safe place for all, please answer the following questions prior to commencement of your appointment ...

First Name

Last Name

Today's Date

Are you feeling well today and completely free of any cold or flu-like symptoms, including very mild symptoms associated with COVID-19?

Yes

Have you felt well and completely free of any cold or flu-like symptoms, including very mild symptoms associated with COVID-19, for the past 14 days?

Yes

Have you been in contact with a known case of COVID-19 OR been in close contact with someone who is unwell/experiencing symptoms associated with COVID-19 in the past 14 days?

Yes

Have you travelled on an airplane in the past 14 days?

Yes

Check this box to confirm the information you have provided is true and correct

Yes