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Studio East - Daily Health Check
Please provide answers to the following questions.
In the last 72 hours have you had any of the following:
1. A new fever (100.4°F or higher)
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YES
NO
2. A new cough that you cannot attribute to another health condition
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YES
NO
3. New shortness of breath that you cannot attribute to another health condition
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YES
NO
4. Other flu-like symptoms that you cannot attribute to another health condition
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YES
NO
5. New muscle aches that you cannot attribute to another health condition, or that may have been caused by a specific activity (such as physical exercise)
*
YES
NO
6. Close contact or exposure to a person diagnosed with or suspected to have COVID-19 in the last 7 days.
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YES
NO
Full Name
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Signature (Parent/Guardian signature if under age 16)
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clear
Today's Date:
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By submitting this form, I verify that the above is true and correct.