Questionnaire

Name

Email Address

Have you or any household members experienced any of the following symptoms within the last 14 days? Have you or any household members experienced any of the following symptoms within the last 14 days? Fever Dry Cough Fatigue Difficulty Breathing None

Have you or any household members been diagnosed with COVID-19 within the last 30 days? Have you or any household members been diagnosed with COVID-19 within the last 30 days? Yes No

Have you or any household members been exposed to anyone diagnosed with COVID-19 within the last 30 days? Have you or any household members been exposed to anyone diagnosed with COVID-19 within the last 30 days? Yes No

Do you have any underlying health conditions that may place you in the High-Risk category if diagnosed with COVID-19? Do you have any underlying health conditions that may place you in the High-Risk category if diagnosed with COVID-19? Yes No

Please Explain.

I understand that I am require to disclose if I am a high-risk individual with any immune deficiencies and/or health risks, and I understand that SRT discourages all high-risk clients from scheduling for his or her own safety? I understand that I am require to disclose if I am a high-risk individual with any immune deficiencies and/or health risks, and I understand that SRT discourages all high-risk clients from scheduling for his or her own safety? Yes No