Medeo Fencing COVID-19 Questionnaire (DAILY)
This questionnaire is intended to screen students prior to the start of every private lesson or group class.
Student Name *
Today's Date (date you are coming in for practice) *
What is your current body temperature? (If you do not have a personal thermometer write "NONE" that below) *
Have you or anyone in your household had a fever or other Covid-19 symptoms (no matter how minor) in the past 14 days? (e.g. Fever, Cough, Shortness of Breath, Sore Throat, Congestion, Headache, Muscle and Joint Pain, Chills, Nausea or Vomiting, Diarrhea) *
If you answered 'Yes', please elaborate on what symptoms:
Have you or anyone in your household tested positive with Covid-19?  *
If 'Yes', please elaborate on who and when they tested positive.
Have you or anyone in your household been in close contact with someone who tested positive with Covid-19 within past 14 days? *
Are you or anyone in your household waiting for Covid-19 test results?  *
Have you or anyone in your household used transportation open to the public in the past 2 months (e.g. buses, Uber, planes)?      *
If 'Yes', please elaborate where you went and when.
Have you or anyone in your household commuted to NYC for work or traveled out of state in the past 2 months?  *
Please list any places you visit on a regular basis (e.g. schools, shopping centers, office buildings) *
Please list any places you visited in the past two weeks (14 days) that are not on a regular basis (e.g. New York City, doctor’s office) *
Check all the measures you agree to abide by in order to begin practicing at Medeo Fencing Club: *
Electronic Signature: By signing with an e-signature (type your first and last name) below, I certify that the information provided in the form is true and accurate and understand the consequences of any misconduct that threatens the health and safety of myself and others. *
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