Covid-19 Screening Questionnaire
Please read and fill out this form completely. Contact me if you have any questions.

Please note that the CDC website lists health conditions that may put people at increased risk for severe illness from COVID-19. If you have any concerns about your own risk factors, please seek advice from your Health Provider to see if massage and bodywork is indicated at this time. It may be best to wait for now and continue physical distancing.

I refer to the updated Vermont Department of Health Travel Map in any instances where you have travelled out of state. Please refer to that website if you have questions about required quarantine following travel.
Client Name (First and Last) *
Have you had a fever in the last 24 hours of 100.4 F or above? *
Have you been advised by a medical professional to self isolate or quarantine at this time? *
Do you now, or have you recently had two or more of the following respiratory or flu symptoms? *
Required
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has Covid-type symptoms? *
Have you traveled outside of the state in the past 14 days? *
Can you exercise to get your heart rate and respiratory rate up without any problem? *
Have you had a new onset of muscle aches and pain since the emergence of the virus? *
Have you seen any new rashes, spots, bumps, or other lesions on your skin? *
Consent for Treatment
I understand that Covid-19 has been declared a global pandemic by the World Health Organization. I understand it is extremely contagious and has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that preventative measures and strict sanitation protocols have been implemented. However, because this work involves close physical contact over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. I acknowledge this risk and give my consent for treatment.
Understanding all of this, I give my consent to receive care, by typing my name below. *
Date *
MM
/
DD
/
YYYY
Consent for Contact Tracing and Agreement to Disclose Future Illness
I understand that in the event a client or practitioner at this office tests positive for Covid-19 within a time period that places me at risk of exposure, my name and contact information will be shared with the Vermont Department of Health for their follow up. In the event that I develop symptoms of illness within 2 weeks of my appointment, I will contact my practitioner immediately.
Client Initials *
Submit
Never submit passwords through Google Forms.
This form was created inside of Tessera Therapeutic Massage. Report Abuse