Coronavirus Intake Form for Massage Therapy

Covid-19 Health Form

For all of our safety, please fill this out prior to each visit (until further notice). Please be sure that the information you give is accurate and complete. Please seek immediate medical attention if you have any symptoms of COVID-19.

First Name *

Last Name *

Email *

example@example.com

Phone Number *

In the past 14 days, I have experienced...

YES

NO

Fever 101°F

Coughing

Sore throat

Shortness of breath

Chills with or without body aches

Recent loss of taste or sense of smell

Unexplained sores on soles of feet

Unusual fatigue

Non-allergy related runny nose

Sudden, unexplained bruising

Travel outside of Connecticu

Unexplained body aches or pain

Signature

Clear

Date