Health screening form for massage with Mischa Bradford, LMT
Please complete before your appointment.
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Do you have any of the following symptoms? Mark any that apply:
*
New and persistent cough
Shortness of breath or any difficulty breathing
Fever (above 100*F)
A loss (or change) in your sense of taste or smell
I have no symptoms.
Have you noticed any new skin marks, lesions, or rashes anywhere on your body?
*
Yes
No
Have you experienced any pain or cramping in your muscles or joints (not attributed to another health issue or physical activity)?
*
Yes
No
Are you on any blood clotting medication?
*
Yes
No
Have you been advised by your doctor to not be active or have found yourself physically unable to be active for any reason?
*
My doctor advised against strenuous activity
I've been unable to be as active as usual
I've been able to continue at my usual activity level
Has anything else in your health history changed since your last appointment? (surgeries, medications, injuries, etc.)
Would you like the table heated for your upcoming session?
Yes
No
Is there anything else you think the therapist should know before your appointment?
Submit
Should be Empty: