Covid 19 Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

To best protect your health and the health of others, please fill out this form
before each massage and bodywork session. Thank you!

Full Name *

Today's Date *

YYYY

Have you been tested for Covid19 *

Yes

When was your test taken?

What were the results?

Have you been in places with a high risk infection rate within the last 2 weeks? (eg. states that are considered "hotspots") *

Yes

Have you had any of these symptoms in the last 2 weeks? *

Fever

Chills

Cough

Sore throat

Diarrhea, digestive upset

Nasal, sinus congestion

Loss of sense of taste or smell

Fatigue

Shortness of breath

Sudden onset of muscle soreness (not related to any specific activity)

Rash or skin lesions (especially on the feet)

I have NOT experienced any symptoms

Required

I declare that the above information is true and accurate to the best of my knowledge *

yes

I understand that there is no cure or vaccine for Covid 19 and that every extra precaution that is taken to clean all surfaces and protection from respiratory droplets (ie. masks) will not guarantee that I will not be exposed to Covid19 from your massage or my office. *

I understand

I agree to let my Massage Therapist know if I have been exposed to someone who has tested positive to covid19 or I have tested positive to Covid19 immediately. *

I agree

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms