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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
No
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
No
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
No
Have you travelled on an airplane in the past 14 days or visited a Tier 1 COVID-19 exposure site as listed by DHHS?
Yes
No
Check this box to confirm the information you have provided is true and correct
Yes
Submit