Health Screening Questionnaire Please enable JavaScript in your browser to complete this form.1) Have you or any immediate family members received the full does of the COVID vaccine? If so, who received and on what date did this occur? *2) Have you or anyone in your household tested positive for COVID-19 within the past 2 weeks? *3) Have you or anyone in your household come in direct contact with anyone who tested positive for COVID-19 in the past 2 weeks? *4) Are you or anyone in your household currently showing signs or symptoms of respiratory illness, cold and/or flu, such as general malaise, cough, fever, or shortness of breath? *5) Have you or anyone in your household exhibited respiratory illness, cold and/or flu symptoms, such as general malaise, cough, fever, or shortness of breath within the past 2 weeks? *6) Have you or anyone in your household recently travelled by air, within the last 14 days? *7) When were the dates that you and your family members last were tested for COVID? Please specify person and approximate dates. **If you answered “yes” to any of the above questions, Kidokinetics reserves the right to refuse serviceLocation Recipient *Select OneSouth FloridaNW Broward, FLTriangle, NCDallas, TexasSouth Valley, UtahCincinnati, OhioPrint Name *Child's Name *Date *Email *Signature *Clear SignatureFile Upload (optional) Click or drag a file to this area to upload. Submit
