Pre-Massage Screening Form

Pre-Massage Screening Form

Please complete at least 3 hours before every visit
Date of Visit*

DayMonthYear
Date
Full Name (no initials)*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Are you currently experiencing any cold or flu-like symptoms? (e.g. fever, cough, sore throat, runny nose, headache, shortness of breath etc.)*

FeverExcessive tirednessDry cough or sore throatShortness of breathRunny noseLoss of smell/tasteUnexplained muscle or joint painVomiting/diarrheaHeadacheLoss of appetiteNone
Have you or any household members experienced any of the above symptoms in the last 7 days?*

YesNo
Are you or any household members currently awaiting results of a test for a contagious illness, or been confirmed with one in the last 7 days?*

YesNo
Please contact me before your appointment if you answered Yes to any question. You may be asked to postpone your appointment.
Declaration

The information I have given is true, correct and complete.

I understand that massage involves touch and close physical proximity over an extended period of time, and that there is an inherent risk of transmission of infectious illness. I have been informed of this risk and consent to receive massage therapy.

For security purposes, submission details including IP address are recorded.
Signature*
Date*

DayMonthYear
Date
Should be Empty: