Covid-19 Screening Questionnaire

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Please read and fill out this form completely. Contact me if you have any questions - this is merely a screener so does not automatically exclude you from receiving a session.

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.

I refer to the Vermont Department of Health guidelines in any instance where you have traveled out of state - recently they announced that except for international trips, travel does not require testing or quarantine.

Client Name (First and Last) *

Have you had a fever in the last 24 hours of 100.4 F or above? *

Yes

Have you been advised by a medical professional to self isolate or quarantine at this time? *

Yes

Do you now, or have you recently had two or more of the following respiratory or flu symptoms? *

Fever

Chills

Sore Throat

A new cough, a worsening chronic cough

Muscle aches

Shortness of breath or difficulty breathing

New loss of sense of taste or smell

Diarrhea or abdominal pain

None of the Above

Required

Have you been in contact with anyone in the last 10 days who has been diagnosed with Covid-19 or has Covid-type symptoms? *

Yes

Have you returned from international travel in the past 14 days? *

Yes

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 *

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 *

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