COVID-19 Supplementary Questionnaire

IMPORTANT:

This is supplementary to the standard Pawprints, Pilates and a piece of Cake Enrolment Form, which must already have been completed.

This form needs to be completed and submitted before your first visit after reopening.

If you have any of the following symptoms or are feeling unwell, please do not come to class:

Fever; a new and continuous cough; loss of taste or smell

 If a member of your household has any of the above symptoms and is waiting for a test,

please self-isolate and do not attend class until the results are known.

Please also refrain from coming to class if you have any of the following symptoms and these are new and unexplained:

shortness of breath; fatigue; loss of appetite; muscles aches and pains; sore throat; headache; nasal congestion; diarrhoea; nausea and vomiting.

If you have you knowingly been in close contact with anyone who has tested positive for Covid-19 in the last 14 days, please do not attend class until 14 days from that contact have elapsed.

 Further advice is available from the NHS Coronavirus Service: https://www.nhs.uk/conditions/coronavirus-covid-19 or call 111 for advice.

Your First Name *
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Last Name *
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Current Address *
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Home Address (if different to above) *
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Please enter a valid email address.
Mobile Phone Number *
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Date of Birth *
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Have you had, or suspect you have had Covid-19 Coronavirus?
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If yes, when? *
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If yes, was this diagnosed by means of a positive test result?
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Have you been admitted to hospital due to Covid-19 symptoms?
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If you have had Covid-19, do you know of any reason you should NOT exercise, or have you been advised not to partake in exercise by a medical practitioner?
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Are you still experiencing symptoms post Covid-19? If yes, please list them: *
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Are you considered to be at extra risk (i.e. clinically vulnerable)?
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Do you have a family member who is vulnerable or extremely vulnerable?
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Are you allergic to specific cleaning products?
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If yes, please give details:
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If there anything else you would like us to know please use this space.
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