COVID-19 Screening Form

Due to the COVID-19 global pandemic, I ask that you complete this survey prior to arriving at the massage studio.

Please complete this survey one to two days before each appointment you have.

I will not be able to accommodate your appointment without having received this survey before you arrive at the studio.

View as single page

Please enter the same email address that was used to book your appointment on MassageBook.

In order to safeguard our community, and because we are not able to social distance during a massage, you will be required to wear a mask for your massage. Please arrive with a mask on. After completion of temperature check and COVID screening, you will be given a clean, disposable mask.

If you are experiencing symptoms related to COVID-19, I ask that you do not come to the massage studio at this time. Please reschedule your appointment for a later date.

Symptoms are listed below:

  • Fever, cough, shortness of breath, or difficulty breathing

If you develop any of the following symptoms (warning signs) for COVID-19, seek emergency medical attention immediately:

  • Trouble breathing
  • Persistent pain or pressure in the chest
  • New confusion or inability to arouse
  • Blueish lips or face


Have you traveled anywhere in the last two weeks that is a location of disease outbreak?

If yes, where did you travel?
When did you return?

Have you been in contact with anyone who was sick?

Have you attended any group functions (five or more people) in the last two weeks?

Have you had any of the following symptoms within the last two weeks:

Have you previously had the SARS-COV-2 virus (novel coronavirus)?

If you have been tested:

What type of test was most recently administered to you?
Date of test:
Test result:

Are you over the age of 65?

Do you have preexisting health conditions related to any of the following:

  • Diabetes
  • Chronic lung disease or asthma
  • Serious heart condition
  • Immunocompromised
  • Chronic kidney or liver disease

Additional comments:

Please click "Submit Responses" below to submit your survey responses.

Thank you for your cooperation. I will contact you if I need further information.

If you have questions, please call or text Derek at 612-367-6773, or email