mxm symptom screener
Please fill out this form each day you have a session. This is a declaration by you about your health and non-risk factors for attendance.

If you answer "YES" to any of the the questions below and cannot explain these symptoms by known allergies or non-infectious illness, then you should not enter our studio.  Please reach out to us via email at info@massagexmadeline.com for more assistance.

This form is automatically date/time stamped for each day of submission.  
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Email *
First + Last Name *
Phone Number (with Area Code) *
Have you had any of the following symptoms in the past three days that are not explained by allergies or a non-infectious cause? *
YES
NO
Cough
Shortness of breath or difficulty breathing
Fever or chills
Muscle or body aches
Sore throat
Headache
Nausea or vomiting
Diarrhea
Runny nose or stuffy nose
Fatigue
Recent loss of taste or smell
Has you been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 in the past 14 days? *
Have you traveled anywhere outside the 50 United States in the past 14 days? *
Have you recently traveled to/from a state that currently has a stay-at-home restriction, a shelter-in-place restriction, or a similar restriction, declaration, or announcement due to a COVID-19 outbreak? *
Have you been directed to quarantine or isolate by the RI Department of Health or a healthcare provider in the past 14 days and if yes, are you past the final date of quarantine or isolation? *
Have you been directed to quarantine or isolate by the RI Department of Health or a healthcare provider in the past 14 days? *
If you answered yes to any of the questions above, we politely ask that you reschedule your session. Your health and the health of all of our clients are paramount. We must be vigilant in our awareness to prevent the spread. Please reach out to us as soon as possible if you anticipate you will miss your session. Thank you!
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