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COVID 19 Screening Form
Cupping Therapy Waiver
Home
Yoga Therapy
SERVICES
Cupping Therapy
Stretch Therapy
Yoga Classes
CLASS SCHEDULE
CLASS SIGN UP
Public Classes
Book
ABOUT
CONTACT
OM VIP
FREE CONSULT
BLOG
EAT
MOVE
LIVE
MEDIA
COVID 19 Screening Form
Cupping Therapy Waiver
*
Indicates required field
Name
*
First
Last
Date of Birth (mm-dd-yyyy)
*
Email
*
1. Have you traveled outside of the USA in the last 14 days?
*
Yes
No
2. Have you traveled within the USA in the last 14 days?
*
Yes
No
3. Have you been on a cruise ship in the last 14 days?
*
Yes
No
4. Have you been in close contact with anyone who has traveled domestically or internationally in the last 14 days?
*
Yes
No
5. Have you attended any events or gatherings with more than 100 people?
*
Yes
No
6. Have you been in close contact with a person known to have the 2019 Novel Coronavirus (COVID-19) in the last 30 days?
*
Yes
No
7. Have you been tested for COVID-19?
*
Yes
No
RESULTS
*
Postive
Negative
N/A
8. Have you been asked to self-quarantine in the last 30 days?
*
Yes
No
9. Do you currently have fever?
*
Yes
No
10. Do you currently have lower respiratory symptoms such as a cough or shortness of breath?
*
Yes
No
11. Do you have a new onset of cold symptoms such as a cough and runny nose?
*
Yes
No
12. Have you received the COVID-19 Vaccine?
*
Yes
No
Agreement
*
By click here, you certify that the answers above are true. Failure to answer truthfully or withholding information intentionally will lead to immediate dismissal from our practice and may be subject to applicable laws during this pandemic.
Today's Date (mm-dd-yyyy)
*
Submit
