COVID Health Screen

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COVID Health Screen

Please fill out and submit this form within 24 hours of your next appointment at Deep Roots Massage.

19Questions

1
Name* This field is required.
First Name
Last Name
2
Have you tested POSITIVE for COVID-19?* This field is required.
YESNO
3
When was your positive COVID-19 test taken?* This field is required.
Date
Year
Month
Day
4
Please tell us about your test:* This field is required.
I tested positive for COVID-19 while I had the disease.
I tested positive for the antibodies for COVID-19 after recovering from the disease.
5
In the last 14 days, have you close contact with someone who is suspected or confirmed to have COVID-19?* This field is required.
YESNO
6
Have you experienced FEVER or CHILLS over the last 14 days?* This field is required.
YESNO
7
Have you experienced a SORE THROAT as a NEW PATTERN over the last 14 days?* This field is required.
YESNO
8
Have you experienced STOMACH UPSET or DIARRHEA as a NEW PATTERN over the last 14 days?* This field is required.
YESNO
9
Have you experienced a COUGH as a NEW PATTERN over the last 14 days?* This field is required.
YESNO
10
Have you experienced a NASAL or SINUS CONGESTION as a NEW PATTERN over the last 14 days?* This field is required.
YESNO
11
Have you experienced a LOSS OF TASTE OR SMELL as a NEW PATTERN over the last 14 days?* This field is required.
YESNO
12
Have you experienced a FATIGUE as a NEW PATTERN over the last 14 days?* This field is required.
YESNO
13
Have you experienced a SHORTNESS OF BREATH as a NEW PATTERN over the last 14 days?* This field is required.
YESNO
14
Have you experienced the SUDDEN ONSET OF MUSCLE SORENESS as a NEW PATTERN over the last 14 days?* This field is required.
YESNO
15
Have you had any new RASH or LESIONS over the last 14 days?* This field is required.
YESNO
16
In the last 14 days, have you traveled internationally?* This field is required.
YESNO
17
Have you resided in New Hampshire for the last 14 days.* This field is required.State guidelines require you to wait 14 days before receiving massage when moving from another state.
YESNO
18
In the last 14 days, have you traveled domestically by TRAIN, BUS or PLANE outside NH, VT or ME?* This field is required.
YESNO
19
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 14 days?* This field is required.
YESNO
20
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