The Great Escape Massage Therapy, LLC

Subtitle

The Great Escape Massage Therapy, LLC

32 Indian Rock Road, Unit 3

Windham, NH 03087


Print Name:____________________________________ Date:_______________________

You will be asked to complete this form at your next visit. At each subsequent appointment you will be asked to verbally confirm that there have been no changes in your answers since the initial form completion.

Please circle Yes or No. Please explain any “Yes” answers in the comment section below.


1. Have you traveled outside of the US in the past 30 days?           Yes  or   No

If yes, please list the locations you have visited below,

Comment:______________________________________________________________________


2. Have you been in close contact with an individual who has        Yes  or   No

traveled outside of the US in the past 30 days?

If yes, please list the locations he/she visited below,

Comment:______________________________________________________________________


3. Have you had any of the following symptoms? Check all that     Yes  or   No

apply.

___Fever over 100.4

___Persistent cough or sore throat

___Shortness of breath

___Diminished sense of smell and/or taste

If yes, how long have you had these symptoms? _______________________________________

If yes, have you been diagnosed and/or seen by the doctor?             Yes  or   No

Comment:______________________________________________________________________


4. Have you been in close contact, in the past 30 days, with an        Yes  or   No

individual who has had any of these symptoms? Check all that

apply.

___Fever over 100.4

___Persistent cough or sore throat

___Shortness of breath

___Diminished sense of smell and/or taste

If yes, have they been diagnosed and/or seen by the doctor?            Yes  or   No

Comment:______________________________________________________________________

If you answered yes to any of the questions above, I will work with you to make accommodations for massage therapy to the best of my ability.


Sign:_______________________________________ Date:___________________________