Health Questionnaire

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

Thanks for supporting efforts to stay vigilant about how ones health and exposures impact others (related to COVID and other viruses). Please review this form and affirm your awareness to typical symptoms affiliated with common illnesses (outside of history with reactions to allergies/allergy season) or participation in the activities indicated below during the past 2 weeks. If yes to any of these questions, please contact me (your massage therapist). Vermont State COVID requirements have been lifted. This information is sought by me (your massage therapist) in an effort to follow guidelines, ensuring self-awareness of ones health, and for managing interactions and my business safely. Thank you.

Name

Date (today)

YYYY

Have you experienced any of these symptoms in the past 10 days? Check all that apply or None.

Dry Cough

Fever

New signs of body ache or headache

vomitting

Shortness of breath/difficulty breathing (If you live with asthma or a respiratory condition, answer yes only if you've observed anything out of the ordinary)

Sore throat

Sinus mucus, runny nose. (other than known seasonal allergies)

NONE!

Have you been positively diagnosed, or known to have been exposed to someone who has been diagnosed, with COVID-19 or other virus in the past 10 days?

Yes

Clear selection

Have you been tested for Covid19 or another virus in the past 2 weeks? What were the test results?

Yes

Negative

Positive

Clear selection

Have you traveled through airports, attended any multi-family or large gatherings (ex, wedding, reunion, indoor concert) and/or been in close contact with someone who has in the past 7 days?

Yes

Clear selection

By clicking "I Agree" below, I acknowledge that I understand that close contact with people increases the risk of infection from COVID-19. I am further aware that massage, by nature requires close contact with my practitioner. I am aware of the risks and give consent to receive massage. I understand that my practitioner will participate in contact tracing if necessary and that in such an instance my name and contact information may be shared with state agencies. I further attest that should I become aware of any outside contact, or myself become symptomatic, or test positive within 14 days of my appointment, I will contact my provider immediately to inform them.

I agree

Clear selection

One of the of the possible complications of COVID-19 is coagulopathy or abnormal blood-clotting. Bodywork stimulates the circulation of blood and bodily fluids, putting those with blood conditions or diseases at higher risk for stroke or heart attack. If you have a blood condition, disease, or have experienced stroke or heart attack in the past, please share this information with your massage therapist prior to receiving bodywork. Click "I Agree" to acknowledge that you understand the risks of receiving bodywork and the importance of sharing health condition information with your wellness provider.

I Agree

Clear selection

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