COVID19 Questions

Selah Massage & Bodywork ~ COVID19 Questionnaire

This Form or the printable version must be submitted before each treatment session beginning June 2020.

* Indicates required field

Name: *

First

Last

Appointment Date: *

1. Have you had a a fever in the last 24 hours of 100°F or above? *

Yes No

2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? *

Yes No

3. Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? *

Yes No

4. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID19 or has coronavirus-type symptoms? *

Yes No

Submit