COVID Screening Questions

Name *

First Name

Last Name

Have you had a fever in the last 48 hours of 100 degrees Fahrenheit or above? *

Yes

No

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus type symptoms? *

Yes

No

Have you traveled our of state in the last 14 days? *

Yes

No

Can you exercise to get your heart rate up without any problem? *

Yes

No

Have you seen any new marks, rashes, spots, bumps, or lesions on your skin? *

Yes

No

Have you had a new loss of taste or smell?

Yes

No

Have you been diagnosed with/suspect you've been positive with COVID-19?

Yes

No

I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner.

Agree