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 been in contact with anyone in the last 14 days who is experiencing these symptoms (without proper PPE)?
*
Yes
No
Have you been in contact with anyone in the last 14 days who has since tested positive for Covid-19 (without proper PPE)?
*
Yes
No
Not Sure
Have you travelled in the last month?
Yes
No
Where did you go?
Have you ever been diagnosed with COVID?
*
Yes
No
Prefer not to say
When were you diagnosed?
less than 2 weeks
2-4 weeks ago
4-8 weeks ago
more than 8 weeks ago
never
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
Have you been fully or partially vaccinated?
Yes, partially (one dose of Moderna or Pfizer)
Yes, fully (both doses of Moderna or Pfizer or one dose of J&J)
Fully vaccinated plus a booster(s)
Not vaccinated
Prefer not to say
When was your last dose?
Which vaccine?
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
Do you agree to wear a mask for the entire duration of your appointment (regardless of vaccination status)?
*
Yes
No
If you or a member of your household develop any symptoms associated with COVID-19 between now and your appointment, do you agree to inform the therapist BEFORE your appointment time?
*
Yes
No
Is there anything else you think the therapist should know before your appointment?
Submit
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