COVID-19 Questionnaire

Client Safety Questionnaire

  • Within the last 14 days, have you or anyone in your household or close to you been diagnosed with COVID-19, cold or flu?

 

  • Are you or is anyone in your household or close to you awaiting the results of a COVID-19, cold or flu test?

 

  • Do you or does anyone in your household or close to you have any of these symptoms?

– cough / runny nose / sore throat
– fever / chills / muscle aches
– trouble breathing
– sudden headaches / fatigue
– loss of taste and / or smell
– nausea, vomiting, or diarrhea

  • Within the last 14 days, have you or anyone in your household traveled internationally?

 

  • Within the last 14 days have you or anyone in your household been on an airplane?

 

  • Within the last 14 days have you hosted or attended an indoor gathering of 10 people or more where guests were unmasked and their vaccination status unknown?