COVID-19 questionnaire

To protect both client and teacher, some simple protocols must be followed. Please review and answer the questionnaire attached below. You will be interviewed again by phone the day before your appointment.

All persons in the studio will wear face masks and other protective equipment unless proof of full vaccination is provided.
Clients will be screened for COVID-19 symptoms before their visit.
All clients will be screened for COVID-19 symptoms upon entering the studio; temperature will be checked with a “no-touch” thermometer.
Clients will use a hand-sanitizer upon entering the office.
Clients will be required to wear a face mask throughout the session unless otherwise agreed between Client and teacher.
Only one Client at a time will be permitted in the studio unless prior agreed upon between Client and teacher.
Clients must arrive AT the time of the visit, not earlier, as the waiting room must remain empty.
Studio will be thoroughly cleaned throughout the day and clinical surfaces will be sanitized before each Client visit.
Administrative tasks, paperwork, will be done by phone and email prior to and following each session.

Have you been vaccinated? Which vaccine? Please bring a copy of your card.

Have you or a member of your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever, temperature at or greater than 100 degrees Fahrenheit? (If yes, who had the symptoms, what were the symptoms, when they start, when did the symptoms stop.)

Have you or a member of your household been tested for COVID-19? (If yes, obtain the date of test, results of the test, whether the person is currently in quarantine and the status of the person’s symptoms.)

Have you or a member of your household been advised to be tested for COVID-19 by government officials or healthcare providers? (If yes, obtain information about why the recommendation was made, when the recommendation was made, whether the testing occurred, when any symptoms started and stopped and the current health status of the person who was advised.)

Were you or a member of your household advised to self-quarantine for COVID-19 by government officials or healthcare providers? (If yes, obtain information about why the recommendation was made, when the recommendation was made, whether the person quarantined, when any symptoms started and stopped and the current health status of the person who was advised.)

Have you or a member of your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? (If yes, obtain the facility name, location, reason for visit/treatment and dates.)

Have you or a member of your household traveled outside the U.S. in the past 30 days? (If yes, obtain the city, country and dates.)

Have you or a member of your household traveled elsewhere in the U.S. in the past 21 days? (If yes, obtain the city, state and dates.)

Have you or a member of your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19? (If yes, obtain the status of the person cared for, when the care occurred, what the care was.)

To the best of your knowledge have you been in proximity to a person who tested positive for COVID-19? (If yes, obtain information about when the contact occurred, what the contact was, how long the people were in contact and when the diagnosis occurred.)

Have you or a member of your household attended an indoor party, conference, or gathering of 10 people or more, including household, restaurant or gym? Were masks worn? (Please provide details.)

Name

First Name

Last Name

Phone

(###)

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Parent/Guardian (For clients and students under 16 years of age)

First Name

Last Name