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.
Name
First Name
Last Name
Email
example@example.com
Phone Number
In the past 14 days, I have experienced...
Yes
No
Fever 101°F +
1
2
Unexplained body aches or pain
3
4
Coughing
5
6
Sore throat
7
8
Shortness of breath
9
10
Chills with or without body aches
11
12
Recent loss of sense of smell or taste
13
14
Unexplained sores on soles of feet
15
16
Unusual fatigue
17
18
Non-allergy related runny nose
19
20
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: