Group Booking, Covid Questionnaire & Consultation
Cotswold Mobile Massage
Your details
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
What's the name of your group booking (the person who's made the booking or the name of the location we're visiting)?
*
Covid Questionnaire
To your knowledge, have you been in contact with anyone with Covid-19 or Covid-19 symptoms in the last 14 days?
Yes
No
Have you been tested for Covid-19?
Yes
No
If yes, how long ago and what were the results?
Are you registered on the NHS Track & Trace app?
Yes
No
Have you recently been unwell including a fever (over 37.8 degrees),a sore throat or runny nose or dry persistent cough? Or chills, headache, pain swallowing, fatigue or exhaustion, muscle or joint ache or loss/change of taste and/or smell?
yes
no
If you've had Covid-19, when did you test positive and is the self-isolation period over?
If you've had Covid-19, are you still experiencing any symptoms?
If you've had Covid-19, have you been screened for DVT? If yes, what were the results. If no, have you experienced any pain, heat, change of colour or swelling in your lower legs?
The following are considered "high risk" factors as provided by the NHS. Please tick any that apply
Heart condition
Severe lung condition (severe asthma, cystic fibrosis, severe COPD)
Receiving radiotherapy or chemotherapy
A considerably compromised immune system
Recent organ or bone marrow transplant
Receiving dialysis
Any other serious medical condition
If yes to any of the above please give details
The following are considered "moderate risk" factors. Please tick any that apply health conditions / factors? Please tick all that apply
Aged 70+
BMI of 40+
Lung condition (asthma, emphysema, mild COPD)
Heart disease
Diabetes (type 1 or 2)
Chronic kidney or liver disease
Neurological disease (Parkinson's, MS, motor neurone)
Currently pregnant
Have a condition or medication that compromises your immune system
Male over 40
Are you medically exempt from wearing a mask?
Yes
No
Have you? (tick all that apply)
Returned from outside of the UK in the last 14 days
Been into hospitalised for reasons other than Covid in the last 14 days
If yes to either of the above please give details
Are you (please tick all that apply)
An NHS frontline worker
A carer
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Consultation Form & Medical History
What type of massage/s have you booked for yourself? (we need this information so we can give your details to the therapist who will be treating you)
Relaxing Therapeutic
Deep Tissue
Facial
Pregnancy
Post Natal
Aromatherapy
Reflexology
Indian Head Massage
Are there any area that are bothering you that you'd like some focus to?
What's your ideal massage pressure?
Gentle
Medium
Firm
Anything you don't like? EG. certain essential oils, areas of your body you don't like having touched
Are you taking any prescribed medications? If yes, please detail
Do you have any medical conditions? If yes, please detail
If you are pregnant, how many weeks are you?
Do you have any allergies or sensitivities? If yes, please detail
Do you have any skin concerns or conditions? If yes please detail
Anything else you'd like us to know?
Declaration
By signing below, I declare that the information I have provided is true and correct. I am aware that by making a false declaration or withholding information could result in detriment to my own health and others. I am aware that purposely withholding or falsifying information is a criminal offence. If either I or someone I have been in contact with tests positive for Covid-19 or have been contacted by a tracing app I will inform you without delay.
Consent
By signing below, I consent to receive massage treatment from a Cotswold Mobile Massage therapist.
Signature
Clear
Thank you for taking the time to complete this form. We look forward to treating you soon.
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