Active Fitness Members Reopening Survey

Question Title

* 1. Have you been in close contact with anyone who are confirmed with having the COVID- 19 virus in the last 14 days?

Yes

No

Question Title

* 2. Do you live in the same household with someone who has symptoms of COVID-19 who has been in isolation for the last 14 days ?

Yes

No

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* 3. Do you have any of the following typical COVID-19 symptoms ; fever, high temperature, persistent coughing or breathing difficulties/ shortness of breath?

Yes

No

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* 4. Have you returned to the Island of Ireland from another country in the last 14 days?

Yes

No

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* 5. If yes where?

Question Title

* 6. I confirm that i have responded to the questions above truthfully based on my current condition and i commit to advising the t team at Active Fitness if this situation changes.

Name

Email Address

Phone Number