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SANDY
BELTRAMINI
ABOUT
SELFATIONSHIP
CONTACT
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.
Full Name
Date of Appointment
Email
Phone
1. Have you traveled outside the US in the past 30 days?
Yes
No
If Yes, Where?
2. Have you traveled to a US city/state with reported cases of Coronavirus in the past 30 days?
Yes
No
If Yes, Where?
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?
Yes
No
4. Have you tested positive for COVID-19?
Yes
No
5. Do you live with OR take care of anyone who has tested positive for COVID-19?
Yes
No
6. Have you tested for COVID-19 and are waiting for results?
Yes
No
7. In the past 14 days, have you experienced any of the following? (check all that apply)
Fever (99.5 and above)
Unexplained body aches or pain
Cough
Sore Throat
Shortness of Breath
Chills with or without body aches
Headache
Recent loss of sense of smell or taste
Unexplained sores of soles of feet
Unusual fatigue
Non-allergy related runny nose
None of the Above
*Please sign within box. If you are having issues, please fill out this form via computer.*
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SELFATIONSHIP PROGRAM
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