Client Session Questionnaire

This questionnaire must be completed within the 24 hours prior to your massage appointment.

This form acts as a supplement, not a substitution, to the Client Health & Information Form, which must be completed prior to a client's first visit.

An accurate and updated report of your health history at each visit is important to ensure that it is safe for you to receive a Massage Therapy treatment. If you have a specific medical condition or specific symptoms, Massage Therapy may be contraindicated. In specific instances, a referral from your primary care provider may be required prior to your Massage Therapy session. All information gathered for your treatment is confidential except as required by law. Written authorization will be required for the release of any information.

New Location as of May 24, 2021:

2305 Commonwealth Drive, Charlottesville, VA 22901

Has your contact information changed since your last visit?

If yes, please update the inputs below. If no information has changed, you may skip the following section and move to the next page.

For the health and safety of our community, declaration of illness (or lack thereof!) is required prior to receiving massage therapy.

Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.

Please read the following statement and check the box below to agree:

I affirm that neither I nor any members of my household...

• have experienced any of the symptoms listed above within the last 14 days. If so, I understand that I must reschedule my appointment for at least 14 days from now.
• have traveled internationally in the last 30 days.
• have traveled to a highly impacted ("hot spot") area within the United States of America in the last 30 days.
• have knowingly been exposed to someone with a suspected and/or confirmed case of the Coronavirus (COVID-19).
• have been diagnosed with the Coronavirus (COVID-19) within the last 30 days.

I knowingly and willingly consent to receive massage therapy during the COVID-19 pandemic. I understand that due to the frequency of visits of other clients to the building, the characteristics of the virus, and the characteristics of massage therapy services, that I have elevated the risk of contracting or becoming an asymptomatic carrier of the virus by being inside the Shala Center and Commonwealth Massage Therapy, LLC office. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious.

I agree to the following new requirements:

• Clients are required to wear a mask at ALL TIMES if unvaccinated (COVID-19 Vaccine) while inside the Shala Center and Commonwealth Massage Therapy, LLC office.  This includes throughout the duration of the massage.
• It is recommended that guests wash their hands in the restroom both upon arrival and after their appointments.
• Social distancing is required whenever possible while inside the Shala Center.
• Guests may not accompany clients to their sessions. Drivers are welcome to wait in their cars, have a seat on the front porch, or walk around the Downtown neighborhood while you are in your session.
• If a client is feeling ill in any way in the days leading up to their massage, they must reschedule their appointment! Medical exceptions to the cancellation policy can be made during this time at the discretion of the massage therapist.

By my electronic signature below, I affirm that I have been truthful with, and take full responsibilty for, my information and answers on all pages of this form.