Health Screening Symptom Checker

Health Screening Symptom Checker

Must be completed each time you have a scheduled appointment. Please complete as early as you can once you’ve received this form so that we may secure your upcoming appointment or so that we may act accordingly for a reschedule in a timely manor. Much Appreciated!
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Health Screening

Best practices to try to minimize the spread of pathogens.
BEST PRACTICES; I am grateful for each of you and am asking you to respectfully reschedule should you feel it’s in all of our best interest. We work very hard to stay in best practices and have taken additional measures in combination with our already high standards in our industries. Every action step helps minimize the chance of contamination though there are no guarantees. Your health, our health and keeping our doors open to safely serve you is our priority. *

Will do
This information is bound by HIPPA and the data collected for contact tracing and state Heath department tracking should a need arise. *

Understood and I consent.
Have you had a fever of or above 100.4F in the last 24 hours? *

Yes No
Do you currently have any immunocompromised symptoms; fever of 100.4 in the last 24 hours, respiratory distress, cold or flu signs such as but not limited to, sore throat, cough, congestion, runny nose, change in sense of taste or smell, or any other symptoms today? *

I will reschedule if I’m compromised/sick in any way.
Have you Traveled; internationally, taken a cruise, or domestically taken public transportation outside of NH, Or non essential travel out side New England in the last 14 days. *

Yes No NOTE check here if this applies: You do NOT need to quarantine for 10 days or get tested forCOVID-19 if either of the following apply: 1. You are fully Inoculated against COVID-19 and more than 14 days past the date completed.2. You have previously tested positive for active COVID-19infection (by PCR or antigen testing) in the last 90 days (if you had a previous infection that was more than 90 days ago, you must still follow all quarantine requirements)
Any non contagious health or body changes I should be aware of? Examples: depression/anxiety, migraines, sports injury, or accident to name a few. *

No
Have you or anyone in your household been in close contact with someone who is suspected or confirmed to have had COVID-19 in the past 14 days? *

Yes No
Are you or anyone in your direct household waiting for test results of any pathogen/contagion? *

Yes No
Are you at all immune compromised? *

Yes No
I have had Covid already, I have completed all my doctors recommendations following my positive test, including a 10day quarantine, and have been fever/ symptom free. (If YES, Please fill out the date you were deemed safe to come out of quarantine, either negative result post infection or date last fever free with out symptoms after the 10days min.past 90days is considered a no again. )(If NO simply type NO) *
I consent to being documented as a client here today in the event that contract tracing needs to occur. *

Yes No
Masks are optional. That said, if you want me to wear one or you are wanting to wear we can. *

I’m going to wear a mask Can we both wear one please No mask today
I will alert you should I have a contagious pathogen positive result for myself, my direct household or someone I was in direct contact with, within a 14 day window surrounding either side of my session.
I agree to the above statement. *

Yes No
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel virus. However, these best practices still offer no guarantee regarding your potential risk of being infected. PLEASE SEE YOUR SERVICE WAIVER AGAIN, SHOULD YOU HAVE ANY QUESTIONS.
I agree to the above statement. *

Yes No
Consent for Treatment

NEW FORM FOR EVERY TREATMENT
I understand the because Massage and Bodywork involve maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission. By signing this form, checking yes you understand and/or submiting the form. I acknowledge that I am aware of the risks involved from recieving treatment and voluntarily agree to assume those risks, and I release and hold harmless my practitioner and 444Hands from any claims related thereto. I give my consent to receive treatment and to follow all guidelines asked of me today to keep the practitioner and business compliant.
I agree to the above statement. *

Yes No
Should I not pass my health screening due to potential Pathogen exposure, since booking this appointment; I understand that Bethany will use her discretion of implementing her 24 hr standard cancellation policy and will proceed accordingly for this appointment based on early arrangements made for my current health condition. *

Yes No
Signature

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Health Screening Symptom Checker

Health Screening

Consent for Treatment