Screening

Health Screening

Reason for seeking treatment
Name

First Name Last Name
Date

Month Day Year
Date
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?

Yes No
Please Describe
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?

Yes No
Please Describe
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?

Yes No
When?
Symptom(s)/Reason(s) for seeking treatment?
List symptoms. (Massage Therapy for fun or just to relax is not considered medically necessary)
Goals for today's treatment:

Reduce Symptomatic Pain Increase Range of Motion
In the past, after massage therapy, my symptoms have

improved significantly improved remained the same gotten worse
Additional notes:
Should be Empty:

Health Screening