Urban Body San Jose Covid-19 Health Questionnaire
All staff and clients must complete this questionnaire every day prior to instructing, working out, or attending any in-studio sessions.

If you answer yes to any of these questions, please stay home and contact your health care provider. If your symptoms are mild, we encourage you to keep your appointment time and instead have a virtual session.

The safety of our clients and staff is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure, we are asking everyone to complete and submit this questionnaire online, or prior to entering the studio. We will have a limited amount of copies available at the studio.

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and our staff.

The information on this form will be maintained as confidential.
Date *
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Name *
Emergency Contact if under 18 *
Do you have a fever or above-normal temperature? *
Are you experiencing shortness of breath, or having trouble breathing? *
Do you have an unexplainable cough or sore throat unrelated to seasonal allergies, or asthma? *
Have you recently lost or had a reduction in your sense of smell or taste? *
Are you experiencing chills, night sweats, or unexplainable body aches? *
Do you have any cold or flu-like symptoms, unexplainable headache, or unusual fatigue or confusion? *
Are you experiencing an upset stomach, gastrointestinal upset, nausea, vomiting, or diarrhea? *
Have you experienced any of the above symptoms in the last 14 days? *
Have you tested positive for Covid-19 in the last 14 days or been exposed to anyone who has tested positive? *
Have you traveled on commercial flights in the last 14 days? *
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