Fever > 38 °C / 100°F  *

YES

NO

Recent cough or intensified chronic coughing *

YES

NO

Shortness of breath or difficulty breathing  *

YES

NO

Runny nose *

YES

NO

Fatigue *

YES

NO

Did you travel in the last 14 days *

YES

NO

Did you have any contact with a COVID-19 positive person in the last 14 days *

YES

NO

Date of your treatment

MM

DD

YYYY

First and Last Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Your address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Do you need an insurance receipt?  *

YES

NO

Is it your first massage ever? *

YES

NO

Are you pregnant? *

YES

NO

Did you have an accident or undergo surgery in the last 2 years? *

YES

NO

Do you have any allergies? *

YES

NO

Do you have any skin problems? *

YES

NO

Did you ever receive cancer treatment? *

YES

NO

Are you on any type of medication? *

YES

NO

Do you have a heart condition? *

YES

NO

Do you have respiratory problems? *

YES

NO

Do you have nervous problems? *

YES

NO

Do you have any muscle or joint problems? *

YES

NO