Robert Williams Therapeutic Massage

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Pre-Massage Daily Qurestionnaire

Questionnaire that will be answered EVERY massage

 

Name__________________________________Date___________________________________

 

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? Yes____ No____

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID19 or has coronavirus-type symptoms? Yes____ No____

Have you been out of the country in the last two weeks?Yes____ No____

Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?Yes____ No____

Can you exercise to get your heart rate and respiratory rate up without any problem?Yes____ No____

Have you had a fever in the last 24 hours of 100°F or above? Yes____ No____

I will be taking your temperature with a touch free device for assessment purposes only. I do not diagnose. Result______

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