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Precautionary COVID19 Health Intake & Liability Release Form
Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, specific health history precautions must be taken with each client. We need to take care of one another at a higher level than ever before. The following Precautionary COVID-19 Health Intake & Liability Release Form is a way of entering a contract that each party will do their part to keep the other safe. Please be 100% honest about your health status.
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Email
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Your email
How did you find this business? (if someone referred you, please state who)
Your answer
A wide variety of complications can accompany or follow infection for some COVID-19 patients. Have you suspected you had or knowingly had COVID-19? •If the answer is no, you may skip to section 2 by scrolling to the bottom of this page and selecting 'NEXT"
*
YES
NO
If yes, how long ago did you have COVID-19?
Your answer
For those that have had COVID-19, what does your medical doctor say about your risk of communicability?
Your answer
For those that have had COVID-19, what does your medical doctor advise about getting physical activity?
Your answer
For those that have had COVID-19, do you have any new (that is, since your infection) discomfort with exertion?
YES
NO
Clear selection
For those that have had COVID-19, do you have any new (that is, since your infection) skin marks, lesions, or rashes, especially on the toes, but anywhere on the body?
YES
NO
Clear selection
For those that have had COVID-19, do you have any new (that is, since your infection) experience of severe deep muscle or joint pain—unrelated to recent physical activity?
YES
NO
Clear selection
For those that have had COVID-19, are you taking any drugs to manage blood clotting?
YES
NO
Clear selection
For those that have had COVID-19, what other long-term consequences of your infection affect your life?
Your answer
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