Respiratory intake form for massage
For all of our safety, please fill this out 24 hours prior to each massage (until further notice). Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
In the past 14 days, I have experienced...
Fever 101°F +
Unexplained body aches or pain
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Non-allergy related runny nose
Should be Empty:
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