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Health Screening Questionnaire
Your safety is our biggest priority. Before entering the building, please fill out the following questionnaire. If you answer yes to any of the questions, please do not enter the building without first checking with Rachel, Sheila or Paulette, (212) 838-2122.
Thank you.
*
Which service(s) on what day(s) do you plan to attend?
*
First Name
*
Last Name
*
Email
*
Phone Number
*
Have you had a diagnosis of or suspected diagnosis of COVID-19 in the past 14 days?
Select One
Yes
No
*
Have you been exposed to confirmed or suspected COVID-19 in the past 14 days?
Select One
Yes
No
Have you had any of the following new symptoms in the past 14 days (not due to a chronic preexisting condition)?
*
fever(100.4 F or higher), chills or shaking
Select One
Yes
No
*
cough, shortness of breath or difficulty breathing
Select One
Yes
No
*
headache
Select One
Yes
No
*
sore throat
Select One
Yes
No
*
muscle aches
Select One
Yes
No
*
diarrhea, nausea, vomiting or abdominal pain
Select One
Yes
No
*
runny nose
Select One
Yes
No
*
new loss of sense of taste or smell (for adults)
Select One
Yes
No
*
In the past 14 days, have you traveled internationally or returned from a state identified by New York State as having widespread community transmission of COVID-19 (other than just passing through the restricted state for less than 24 hours)? Visit https://coronavirus.health.ny.gov/covid-19-travel-advisory for more information.
Select One
Yes
No
Wed, January 27 2021 14 Shevat 5781