Coronavirus Intake form for Massage Therapists

This form must be completed and returned no earlier than 24 hours prior to your treatment. It is important that the information you provide is honest and accurate. If you or someone in your household has any of the symptoms listed below, or has recently returned from international travel, you should isolate.

Your form will be securely kept on record by the therapist, and the information within shall only be shared should it be necessary for contact tracing.

Name*

First NameLast Name

Email*

example@example.com

	Yes	No
If you or anyone in your household or support bubble has had COVID-19, are you still in the self or household isolation period?
Are you waiting for a COVID-19 test or test results?
Have you entered or returned to the UK in the last 10 days?
If you have been notified by NHS Test and Trace that you've been in contact with a person with COVID-19, are you still in the isolation period?

Do you, does anyone in your household, or does anyone in your support bubble, have any symptoms of COVID-19, or have you experienced any of these symptoms in the last 7 days?

	Yes	No
Temperature of 37.5°C +
Unexplained body aches or pain
Diarrhoea
Sore or "tickley" throat
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unusual fatigue
Non-allergy related runny nose
Severe headache

Have you received a COVID-19 vaccination?

Yes: one doseYes: two dosesNo

Please remember that it is still possible to catch and spread the virus even if you have been vaccinated or have had the virus before, and in these cases you may not experience symptoms. Regular lateral flow testing is encouraged as a matter of courtesy, particularly in the days prior to your treatment.

Due to the close contact nature of bodywork and the high number of clients I am in contact with, it is very important that you do not attend your appointment if you are feeling unwell, if you suspect you have been in contact with someone who has Covid-19 symptoms, if you have returned from international travel in the last 10 days, or if you have been contacted by Track & Trace and instructed to isolate.

Signature

COVID-19 Client Intake Form