COVID-19 Health Intake Form Addendum
To best protect your health and the health of others, please fill out this form before each massage and Bowenwork session. Thank you!
Client Name *
Today's Date *
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Have you been tested for COVID-19? *
If yes, what type of test did you have? When was your test? What were the results?
Have you had a fever in the last 24 hours of 100°F or above? *
Do you now, or have you recently had, any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)? *
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *
Have you traveled anywhere outside of the state in the last two weeks? *
If yes, where have you traveled?
Have you had a new loss of sense of taste or smell? *
Reason for today's session: *
By typing your initials you declare that the information above is true and accurate to the best of your knowledge. *
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