1415 West Belmont Avenue Chicago, IL, 60657

773.388.3356

This COVID-19 questionnaire must be completed PRIOR to arriving at Blade Hair Skin Body, but ONLY on the day of your scheduled appointment.

Full Name

First Name

Last Name

Have you recently had ANY of the following symptoms?

-Fever -Cough -Congestion -Sore throat -Runny nose -Shortness of breath -Muscle aches with flu-like symptoms -Loss/decrease of taste or smell -Chills or shaking chills -Headache -Diarrhea, nausea, decreased appetite, or any GI symptoms

2. Have you tested positive for COVID-19 in the last 14 days?

3. Are you living with anyone quarantined for (or has tested positive for) COVID-19 in the last 14 days?

Is your temperature 100 degrees Fahrenheit or higher?

Please use oral thermometer for more accurate reading.

Do you have any other reason to believe that you may be at risk of being exposed to Covid-19?