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.

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Your name:
Email address:
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.

I will arrive at my appointment wearing a face mask. I will wear a mask during my massage.

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

I am not currently experiencing a 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

I have reviewed the above warning signs and understand the importance of seeking emergency care immediately if I develop any of these symptoms.

Questionnaire

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

Yes

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

No, I have not recently traveled to a location of disease outbreak.

Have you been in contact with anyone who was sick?

Yes No, I have not been in contact with anyone who is sick.

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

Yes No, I have not attended any group functions.

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

Yes No, I have not had the SARS-COV-2 virus.

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?

Yes No, I am not 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

Yes (if yes, I will contact you to discuss additional safety protocols.) No, I do not have any of these preexisting health conditions.

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 derekj@relaxrenew.net.