COVID-19 Pre-Screening Questionnaire

    The safety of our employees, customers, families and visitors remain Body Contour Studio’s overriding priority. As the Coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, Body Contour Studio will be monitoring the situation closely and will periodically update company guidance based on current recommendations from the World Health Organization.

    What can I do to protect myself from Coronavirus?
    • Wash your hands frequently throughout the day with soap and water for at least 20 seconds.
    • Disinfect frequently touched objects and surfaces to help prevent the spread of the virus.
    • Avoid close contact with people who are sick, cover your cough or sneeze with a tissue, and avoid touching your eyes, nose and mouth.
    • Stay home when you are sick, except to go to the doctor or hospital.

    What are the symptoms of the Coronavirus?
    Coronavirus symptoms include fever, cough and shortness of breath. Symptoms may appear 2-14 days after exposure.

    To prevent the spread of COVID-19 and reduce the potential risk of exposure to our staff and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone. Thank you for your time.

    1. Patient contact details



    2. Did you travel outside of the country/state in the last 14 days?

    3. Have you had contact with a known or possible COVID-19 case in the last month?

    If No, please enter N/A. Else if Yes, please provide further information including date of last contact:

    4. Have you experience any cold or flu-like symptoms in the last 3 weeks? Such as Arthralgia, Cough, Conjunctivitis, Diarrhea, Fatigue, Fever, Vomiting , Pneumonia, Chills or rigors, respiratory illness, difficulty breathing?

    If No, please enter N/A. Else if Yes, please provide further information including date of last symptoms:

    5. Do you CURRENTLY have any cold or flu symptoms (cough, runny nose, fever, or sore throat, but not seasonal allergies)?

    If No, please enter N/A. Else if Yes, please provide further information including date of last symptoms:

    If the answer is “yes” to any of the questions, access to the facility will be denied. Please urgently contact Body Contour Studio to reschedule your appointment.

    Signed