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) *

YES

NO

2. A new cough that you cannot attribute to another health condition *

YES

NO

3. New shortness of breath that you cannot attribute to another health condition *

YES

NO

4. Other flu-like symptoms that you cannot attribute to another health condition *

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 *

YES

NO

Full Name *

Signature (Parent/Guardian signature if under age 16) *

clear

Today's Date: * +

By submitting this form, I verify that the above is true and correct.