Covid-19 Questionnaire
This form is required by anyone visiting the WeBreathe Wellness or SheBreathes Studio for the first time. If you answered YES to any questions above please email the studio at jenn@webreathewellness.com.
Name: *
Email: *
Phone Number: *
In the past 14 days, have you traveled outside of your local area to any foreign country or area within the U.S. with a CDC Level 3 travel notice or similar State notice? *
In the past 14 days, have you been in close contact with someone (family, friend, or coworker) who returned from (a) any foreign country or (b) an area within the US with a CDC Level 3 travel notice or similar State notice? *
In the past 14 days, have you been in close contact (within six feet) of a person for more than ten minutes with possible Coronavirus Infection? *
In the past 14 days, have you tested positive for or been infected with Coronavirus (COVID-19)? *
Do you have (or have you had in the past 14 days) any of the following symptoms: Respiratory illness, fever, cough, headache, sore throat, runny nose, shortness of breath, loss of sense of smell, unusual fatigue, body aches, or loss of smell or taste? *
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