Covid Symptom Questions
Have you had any of these symptoms in the past 2 weeks? If yes to any of these questions, please contact your massage therapist to reschedule your appointment. This information is documented and kept in an effort to follow Vermont state guidelines to slow the spread of covid19.
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Name *
Date *
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Dry Cough
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Fever *
Shortness of breath/difficulty breathing. (If you live with asthma or a respiratory condition, answer yes only if you've observed anything out of the ordinary) *
Chills *
New signs of body ache or headache *
Sore throat *
Have you been exposed to someone who has COVID-19 in the past 2 weeks *
Have you traveled out of state in the past two weeks? Please adhere to current travel mandates in the state of VT, which may change from time to time. *
Have you been tested for Covid19 in the past 4 weeks? What were the test results?
Are you fully vaccinated? *
By clicking "I Agree" below, I acknowledge that I understand that close contact with people increases the risk of infection from COVID-19. I am further aware that massage, by nature requires close contact with my practitioner. I am aware of the risks and give consent to receive massage. I understand that my practitioner will participate in contact tracing if necessary and that in such an instance my name and contact information may be shared with state agencies. I further attest that should I become aware of any outside contact, or myself become symptomatic, or test positive within14 days of my appointment, I will contact my provider immediately to inform them. *
One of the of the possible complications of COVID-19 is coagulopathy or abnormal blood-clotting. Bodywork stimulates the circulation of blood and bodily fluids, putting those with blood conditions or diseases at higher risk for stroke or heart attack. If you have a blood condition, disease, or have experienced stroke or heart attack in the past, please share this information with your massage therapist prior to receiving bodywork.  Click "I Agree" to acknowledge that you understand the risks of receiving bodywork and the importance of sharing health condition information with your wellness provider. *
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