Respiratory intake form for massage For all of our safety, please fill this out 24 hours prior to each massage (until further notice). Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs. Date of birth* In the past 14 days, I have experienced... Yes No Fever 101°F + Unexplained body aches or pain Coughing Sore throat Shortness of breath Chills with or without body aches Recent loss of sense of smell or taste Unexplained sores on soles of feet Unusual fatigue Non-allergy related runny nose I agree that I am providing accurate health information. * Signature Clear Submit
