COVID Health Screen

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With solid precautions, attention to detail, and help from our clients; Deep Roots has remained open since June of 2020 without incident and we’re grateful and excited to see clients who now feel safe enough to receive a massage!

While being vaccinated can protect someone from serious harmful effects of covid, it does not necessarily prevent the possibiltiy of getting and spreading the disease. As massage involves close contact in small quarters, it’s still important for us to keep doing what we can to prevent spread.

Whether you are vaccinated for COVID or not, please continue to schedule your appointment at least 10 days after traveling internationally or coming into contact with someone with covid or experiencing any related symptoms of the disease.

Please call 603-352-0734 with questions or if you need to reschedule. Thanks!

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Name* This field is required.

First Name

Last Name

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I agree to read and answer all of the following questions carefully.

I acknowledge:

that the Deep Roots Massage staff are taking precautions outside of work to reduce the possibility of spreading covid.
that even the mildest symptoms of a cold would prohibit any Deep Roots employee from working until they receive negative test results.
that I can reschedule my appointment at no charge.

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Signature* This field is required.Thank you! We are counting on each other to protect people who are vulnerable to severe illness due to COVID-19.

Clear

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In the last 10 days, have you been in close contact with someone who is suspected or confirmed to have COVID-19?* This field is required.

YESNO

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Are you a healthcare worker who dons appropriate PPE while caring for people who are suspected or confirmed to have COVID-19?* This field is required.

YESNO

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Have you experienced FEVER or CHILLS over the last 10 days?* This field is required.

YESNO

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Have you experienced a SORE THROAT as a NEW PATTERN over the last 10 days?* This field is required.

YESNO

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Please briefly describe your symptoms of a SORE THROAT, when you had them last, and what you think the cause is or was.* This field is required.

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Have you experienced STOMACH UPSET or DIARRHEA as a NEW PATTERN over the last 10 days?* This field is required.

YESNO

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Please briefly describe your symptoms of STOMACH UPSET, when you had them last, and what you think the cause is or was.* This field is required.

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Have you experienced a COUGH as a NEW PATTERN over the last 10 days?* This field is required.

YESNO

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When did you last experience your COUGH and what you think the cause is or was?* This field is required.

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Have you experienced a NASAL or SINUS CONGESTION as a NEW PATTERN over the last 10 days?* This field is required.

YESNO

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When did you last experience NASAL or SINUS CONGESTION and what you think the cause is or was?* This field is required.

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Have you experienced a LOSS OF TASTE OR SMELL as a NEW PATTERN over the last 10 days?* This field is required.

YESNO

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Have you experienced a FATIGUE as a NEW PATTERN over the last 10 days?* This field is required.

YESNO

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When did you last experience FATIGUE, and what you think the cause is or was?* This field is required.

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Have you experienced a SHORTNESS OF BREATH as a NEW PATTERN over the last 10 days?* This field is required.

YESNO

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Have you experienced the SUDDEN ONSET OF MUSCLE SORENESS as a NEW PATTERN over the last 10- days?* This field is required.

YESNO

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Please briefly describe your symptoms of the SUDDEN ONSET OF MUSCLE SORENESS, when you had them last, and what you think the cause is or was.* This field is required.

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Have you had any new RASH or LESIONS over the last 10 days?* This field is required.

YESNO

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Please briefly describe your symptoms RASH or LESIONS, when you had them last, and what you think the cause is or was.* This field is required.

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Have you been fully vaccinated against COVID-19?* This field is required.

YES I Have.NO, or I'd rather not say.

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Over the last 10 days, have you or anyone in you household traveled internationally?* This field is required.

YESNO

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Over the last 10 days, have you traveled internationally?* This field is required.

YESNO

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In the last 10 days, have you or anyone living in your household traveled by TRAIN, BUS OR AIRPLANE?* This field is required.

YESNO

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Do you have any reason to believe that you or anyone in your household has been exposed to or acquired COVID-19 in the last 10 days?* This field is required.

YESNO

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