Covid Questionnaire

Participant Name

First Last

Phone

Email

What date does your program start?

Have you recently experienced any of the following symptoms (Please select all that apply):

Fever (100.4°F/38°C or higher) or chills?
Cough that you cannot attribute to another health condition?
Shortness of breath or difficulty breathing that you cannot attribute to another health condition?
Sore throat that you cannot attribute to another health condition?
Muscle aches that you cannot attribute to another health condition, or that may not have been caused by a specific activity (such as physical exercise)?
Loss of taste or smell?
None of the above

Have you been in contact with an individual who has been ill with flu-like symptoms in the last 14 days?

Have you been diagnosed with COVID-19 in the last 90 days?

Please enter the date you were notified that you were no longer contagious with COVID-19.

Have you been tested for COVID-19 within the last 7 days?

Covid Test Results

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Upload your test results or if you don't have electronic documentation input your information manually below

When was the test?

What were the results?

Have you been fully vaccinated for COVID 19?

Which vaccine product did you receive?

Date of first dose

Date of second does

Have you received a booster shot?

Date of Booster Shot

Todays Date

Participant Signature

Parent/Legal Guardian Signature

If participant is a minor, a parent or legal guardian needs to sign.

Parent First and Last Name

Date