Self-Assessment Questionnaire
Coronavirus (COVID-19) Self-Assessment helps you check yourself for coronavirus symptoms.

This self-checker is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a medical professional for serious symptoms or emergencies.
You must answer the following questions no more than 24 hours prior to participating in a group fitness class.
Email address *
Participant First & Last Name *
Phone Number *
1. Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus? *
If you answered "yes" to question #1 you are subject to the SF Health Order Isolation Directive. DO NOT GO TO CLASS and contact Kickit365 manager at admin@kickit365.com immediately.
2. Do you live in the same household with, or have you had "close contact" with someone who in the past 14 days has been in isolation for COVID-19 or had a test confirming they have the virus? *
If you answered "yes" to question #2 you are subject to the SF Health Order Quarantine Directive. DO NOT GO TO CLASS and contact Kickit365 manager at admin@kickit365.com immediately.
3. Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by other reason? *
Yes
No
Fever (100.4 F or 38 C or greater)
Chills or Repeated Shaking/Shivering
Cough
Sore Throat
Shortness of Breath
Difficulty Breathing
Feeling Unusually Weak or Fatigued
Loss of Taste or Smell
Muscle Pain
Headache
Runny or congested nose
Diarrhea
Nausea or Vomiting
If you answer is "Yes" to ANY symptom in question #3, DO NOT COME TO CLASS you might have COVID-19 and must be tested for the virus before returning to class. Without a test we must treat you as being positive for COVID-19 and require you to stay out of the class for at least 10 calendar days. In order to return to class and to protect those around you, you must get tested for the virus. Contact your healthcare provider about getting tested for the virus, or sign up for free testing at CityTestSF. Wait for your test results at home while minimizing exposure to those you live with. If your result is positive DO NOT COME TO CLASS. If your result is negative, DO NOT COME TO CLASS until you have had at least 3 days in a row without fever and with improvements in your other symptoms. Consult with your healthcare provider and also contact the Kickit365 manager at admin@kickit365.com. All information provided will remain confidential.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy