Holistic Reiki by Heather Brown: COVID-19 Self Screening Questionnaire

COVID-19 Self Screening Questionnaire

Holistic Reiki by Heather Brown
Name

First NameLast Name
Date of Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Have you had any of the following symptoms in the last 24 hours?

Rows	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:

Rows	Yes	No
Fever
Chills
Headache
Sore throat
New loss of taste or smell

In the last 14 days have you:

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been diagnosed with COVID-19?
Traveled outside of Ontario, internationally or taken a cruise?

If you answered “Yes” to any of the above, please DO NOT attend your appointment. You should self quarantine for at least 14 days, then we will reschedule your appointment.

When you arrive:
1. Please wear a Mask into the room. When seated, you may take it off if you wish.
2. Use Hand Sanitizer at the door.
3. Bring minimum items into the room.
4. Payment should be made before your session via e-transfer or cash in envelope.
Note: NO HANDS ON during your session. However, you will be able to use the Reiki table for your journey.

I certify to the best of my knowledge; this information is accurate.
Should be Empty: