ClientCovidInfo

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A New Truly
Massage and Bodywork Services
Times and Location
- 1001 Sneath Ln, Suite 105

This document contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and let me know if you have any questions.

* Indicates required field

Name *

First

Last

Email *

Have you been tested for COVID-19? *

Yes No

If Yes, what was the Result *

In the Last 14 days, have you been in contact with anyone who has been diagnosed with COVID-19 or has had CoronaVirus-type symptoms. *

In the Last 14 days, have you been asked to self-isolate or quarantine by a doctor or local public health official? *

In the Last 14 days, have you been somewhere with a high infection rate? *

Do you now, or have you recently experienced, any of the following as a NEW PATTERN since the beginning of the pandemic: *

NO If YES, please check all that apply Fever Chills Shortness of Breath Cough Sore Throat Nasal or Sinus Congestion Loss of Taste or Sense of Smell Persistent Chest Pain or Pressure Discomfort with exertion or exercise Diarrhea or digestive upset Skin Marks, lesions or rashes (especially on the feet Fatigue Sudden onset of muscle soreness (not related to a specific activity Discomfort with exertion or exercise

If you tested positive for COVID-19 or believe you may have had COVID-19, but were not tested: *

This does not apply to me because I have not tested positive for Covid-19. My medical doctor has cleared me to return to work or to end self-isolation? My medical doctor advised me to return to normal activity levels? I am not taking any drugs to manage blood clotting.

Describe your Daily Physical Activity (Work, School, Exercise) since the pandemic. *

Thank you for filling out the Covid-19 paperwork for Truly Bodywork. We will contact you after receiving your completed information to confirm your appointment.

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