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Louisa Harris Pilates: COVID-19 Supplementary Questionnaire (Form CVSQ)

IMPORTANT NOTE:
 
This is supplementary to the standard Body Control Pilates Enrolment Form, which must already have been completed.
 
This form only needs to be completed and submitted before your first visit after reopening.     

YOU NEED TO COMPLETE EVERY SECTION IN ORDER TO SUBMIT THE FORM

IMPORTANT ADVICE

If you have any of the following symptoms or are feeling unwell, please do not come to class:
-Fever; a new and continuous cough; loss of taste or smell

If a member of your household has any of the above symptoms and is waiting for a test, please self-isolate and do not attend class until the results are known.

Please also refrain from coming to class if you have any of the following symptoms and these are new and unexplained:
-shortness of breath; fatigue; loss of appetite; muscles aches and pains; sore throat; headache; nasal congestion; diarrhoea; nausea and vomiting.

If you have you knowingly been in close contact with anyone who has tested positive for Covid-19 in the last 14 days, please do not attend an outdoor or indoor class until 14 days from that contact have elapsed.

Further advice is available from the NHS Coronavirus Service: https://www.nhs.uk/conditions/coronavirus-covid-19 or call 111 for advice.

Thank you for providing the above information, which will be stored securely and used in complete confidence.

Please complete this form by entering your details and submitting them using the button at the end of the form.  Alternatively you may email your replies to me if easier.

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Name *
Please enter full name
Current address *
Please enter current address
Home address (if different to current address above)
Please enter home address or n/a if not different
Contact number *
Please enter best contact number to use
Email address *
Please enter current email address
Date of Birth *
Please enter DOB
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Emergency contact - name and phone number *
Please enter Emergency contact details
1. Have you had, or suspect you have had Covid-19 Coronavirus? *
Required
2. If yes, when?      
Please enter n/a if relevant
3. If yes, was this diagnosed by means of a positive test result? *
Required
4a. Have you attended the Emergency Department or been admitted to hospital due to Covid-19 symptoms? *
Required
4b. Note: If you answered ‘Yes’ to Question 4, has your doctor given you permission to exercise? *
Required
5a. Are you still experiencing symptoms post Covid-19? *
Required
5a. Are you still experiencing symptoms post Covid-19? If yes, please list them:   
Please enter n/a if relevant
6. Are you an NHS front line worker? *
Required
7. Are you a carer in a care home? *
Required
8. Are you considered to be at extra risk (i.e. clinically vulnerable)? *
Required
9. Do you have a family member who is vulnerable or extremely vulnerable? *
Required
10a. Are you pregnant?      *
Required
10b. If yes above, how many weeks?
Please enter n/a if relevant
11a. Are you allergic to specific cleaning products? *
Required
11b. If yes above, please give details:     
Please enter n/a if relevant
YOUR SIGNATURE - I confirm that the above information is accurate and give consent for my contact details to be given to NHS Test and Trace should this be required. *
Required
I have read and understood the ‘Important Advice’ above and will contact my teacher about any future change in my circumstances. *
Required
Please enter your name in lieu of hard copy signature *
Date completed this form *
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