Health Assessment

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HEALTH ASSESSMENT

PLEASE FILL OUT THE FOLLOWING
Form must be filled out prior to entering class.

* Indicates required field

Name *

First

Last

Date *

Format ( 00-00-0000 )

Month *

Day *

Year *

HAVE YOU EXPERIENCED ANY OF THE FOLLOWING COVID-19 SYMPTOMS IN THE PAST 14 DAYS? *

Fever or chills Cough Shortness of breath Difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting None of the above

Have you tested positive taking a COVID-19 test in the past 14 days? *

Yes No

Have you been in close contact with a confirmed or suspected COVID-19 case in the past 14 days? *

Yes No

Submit

HAVE A QUESTION? CONTACT US NOW!

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Studio Location *

Comment *

Submit

CONTACT

Call
631-605-7297

Email
[email protected]

LOCATIONS

Free Spirits Yoga - Sayville
247 W. Main Street Sayville, NY 11782

Free Spirits Yoga - Miller Place
491 N Country Rd Miller Place, NY 11764

Info
CLASS SCHEDULE
TRAININGS
Healing Services
Events & Parties