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Note: This form will need to be completed online within 24 hours prior to each session. You'll receive a link to it the day before your session. Thank you for working with me on this! It'll go fast.

Pre-Session Health Check-In

To best protect your health and the health of others, please fill out this form before each session. Thank you!

 

  1. Have you been tested for COVID-19? If yes, what type of test did you have? Date? Results?
     

  2. Have you been exposed to COVID-19 or been providing care for someone experiencing COVID-like symptoms?
     

  3. Have you traveled outside of Southeast Michigan or been in places with a high infection rate within the last two weeks? If yes, please describe. 
     

  4. Have you been asked to self-isolate or quarantine by a doctor or a local public health official in the last 14 days? 
     

  5. Are you using an anti-coagulant to treat complications related to COVID? 
     

  6. Can you exercise to get your heart rate and respiratory rate up without any problem or discomfort? 
     

  7. Have you had a new onset of muscle aches and pain since the emergence of the virus? 
     

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

  9. Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic.

  • Fever             

  • Chills

  • Cough

  • Sore throat

  • Diarrhea, digestive upset

  • Nasal, sinus congestion

  • Loss of sense of taste or smell

  • Fatigue

  • Shortness of breath 

 

I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive bodywork from this practitioner.

 

I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this location tests positive for COVID-19. Only my contact details will be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department
 

__________________________________________________________________

TO BE COMPLETED IN-OFFICE

 _____ Nothing on this form has changed since my intake call yesterday.

 _____ I have made changes where needed.

 

I state that the information provided above is true and accurate to the best of my knowledge.
 

______________________________________________                                             (signature – parent/guardian if minor)

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