Classic Body Restoration COVID-19 Screening Questions

Classic Body Restoration COVID-19 Screening Questions
Please answer the following covid screening questions prior to your appointment. All responses must be submitted at least 1 hour prior to your booked massage.
If anything changes prior to your appointment, please let me know.
Upon entering the building, please wash your hands with warm, soapy water for at least 20 seconds. Bathroom code 3808.
Wear a well fitting mask that covers the nose and does not have a vent. 3 layered cloth masks or N95s work best. Masks are required for the entire appointment.
Your temp will be taken at the door. If your temp is over 100.3 your massage will be rescheduled.
If you are pregnant, you will need to get a doctors release and reschedule with a different provider.
Have you been tested for Covid-19 in the past 14 days because you have symptoms or have been exposed to someone with Covid-19?*
YesNo
Have you, or anyone in your household or pod, come in close contact (within 6 feet) with someone who has a suspected or confirmed COVID-19 diagnosis in the past 14 days?*
YesNo
Have you had a positive Covid-19 test in the past 90 days?*
YesNoYes but have since tested negative twice

In the past 14 days have you had a new or worsening:*

	Yes	No
Cough
Fever
Chills
Sudden loss of taste or smell
Muscle or body aches not from working out
Shortness of breath or difficulty breathing
Fatigue
Runny nose or congestion
Sore throat
Nausea or vomiting
Diarrhea
Acute headache
Does anyone in your household or pod have any of these symptoms?

In the past 14 days, have you traveled out of the state (except within the Portland metro area) or by commercial air, train, bus, or internationally?*
YesNo
In the past 14 days, have you gathered indoors with more than 6 people or with people from more than 2 households?*
YesNo
If you have recently been sick, not with Covid-19, please refrain from coming in for your massage until it's been at least 10 days from the onset of symptoms and you've been symptom free for 48 hours without medication.

If the answer to any of these questions is yes, we will need to reschedule your massage to a later date.
Name*
First NameLast Name
Date*
MonthDayYear
Date
Signature*
Clear
If you have not yet filled out our COVID-19 waiver and intake form, please check your confirmation email for the link and return it before your appointment.
(Only needs to be filled out once)
Thank you!
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