COVID-19 Precautionary Questionnaire 

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precaution with the intake of each client, health history review, as well as sanitation and disinfection practices

Questionnaire

Have you or any household members experienced any of the following symptoms within the last 14 days?

Have you or any household members been 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?

Do you have any underlying health conditions that may place you in the High-Risk category if diagnosed with COVID-19?

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?

14 + 13 =