Mandatory Self-Health Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Before participating in one of Yoga 170's in studio classes, you are required to evaluate your health by completing the following Self-Health Questionnaire. This form must be completed prior to participating. This is a NYS requirement.

Name *

Your phone number *

You are required to answer all questions and you must respond YES to all questions in order to participate.

I confirm that I HAVE NOT tested positive for COVID-19 in the last 14 days. *

Yes

Required

I confirm that I HAVE NOT been in close physical contact with anyone who is either confirmed or suspected to be infected with COVID-19 in the last 14 days. *

Yes

Required

I confirm that I HAVE NOT traveled in the last 14 days to any location that New York State has designated as requiring a 14-day self-isolation after returning due to high incidence of COVID-19. *

Yes

Required

I confirm that I HAVE NOT experienced any symptoms associated with COVID-19 in the past 14 days. If I have experienced any symptoms I have discussed my symptoms, as listed below, with my doctor and have confirmation they are not related to COVID-19. The symptoms are: Fever (>= 100.4 degrees Fahrenheit, Cough, Shortness of breath or difficulty breathing, Chills, Repeated shaking with chills, Muscle Pain, Headache, Sore Throat, New Loss of Taste or Smell. *

Yes

Required

By submitting this form, I attest this information is true and accurate.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of YOGA 170, LLC.

Does this form look suspicious? Report

Forms