SANDY BELTRAMINI

Client Screening Questionnaire

Your cooperation and compliance will help to ensure your health and safety as well as the safety of others. Until further notice, please fill out a health questionnaire 24 hours prior to every massage appointment. Be sure that the information you provide is accurate and complete.

All accompanying Aide’s must also complete this form for each appointment.
1. Have you traveled outside the US in the past 30 days?
2. Have you traveled to a US city/state with reported cases of Coronavirus in the past 30 days?
3. Have you been in personal contact with a person infected with Coronavirus or who has traveled to an area with widespread and transmission of COVID19 in the past 30 days?
4. Have you tested positive for COVID-19?
5. Do you live with OR take care of anyone who has tested positive for COVID-19?
6. Have you tested for COVID-19 and are waiting for results?
7. In the past 14 days, have you experienced any of the following? (check all that apply)

*Please sign within box. If you are having issues, please fill out this form via computer.*

Thank you for submitting!