COVID-19 Health Screen for Massage Therapy Clients
In order to help prevent the spread of the novel Coronavirus, please answer the following questions. Be sure to note the list of pre-existing conditions which could put you more at risk. Depending on the nature of your condition(s), be aware that you may be denied for services at this time. Please keep in mind that this is intended to protect, not discriminate. Clients will be asked to wait 14 days before scheduling an appointment if any of the following apply: In the last two weeks you've experienced symptoms, traveled out of state to a 'hot spot' area, or been around someone who tested positive.
Email address *
Please list your DATE OF BIRTH. *
Please list your NAME *
Have you been asked to self-isolate or quarantine by a doctor or public health official in the last 14 days? *
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, chills, cough, sore throat, digestive issues, fatigue, muscle achiness, shortness of breath or other respiratory problems)? *
If yes, please list and explain if not related to COVID-19.
Have you had close contact with or cared for someone diagnosed with COVID-19, or someone exhibiting cold or flu-like symptoms in the last 14 days? *
Have you been in places with a high infection rate within the last two weeks (e.g. state-designated "hotspots")? *
If yes, please explain.
Have you been tested for COVID-19 in the last two weeks? *
If yes, What type of test did you have, When were you tested, and What was the result?
Have you been vaccinated for Covid-19? *
If yes, When did you receive the vaccination?
Unless fully vaccinated or otherwise directed by your primary healthcare provider, clients at higher risk of severe illness from COVID-19 should forgo massage while the virus remains in our community. That includes individuals with the following conditions. Please check if any apply to you:
Please provide further explanation, if necessary.
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