Pre-screening Covid 19 Session

Practitioner/Clinic Name: ________ Screening Questionnaire
Contact Information: ____________ (page 1 of 2)
Client Information
Client Name: ________________________________________________ Date: ________
Preferred phone number: ___________ Best time to call: ____________________
Email address:_______________________ Preferred form of communication: _______
Massage Information
How did you hear about me? (referral, Facebook, etc.) ________________________
Is this a gift certificate? Yes ☐ No ☐
Massage history:
Have you had a massage/bodywork before? Yes ☐ No ☐
Frequency: ________________________
Types of massage/bodywork received: ________________________
Preferred types of massage: ________________________
Reasons for seeking massage? (relaxation, injury, etc.)

Description of injury/health condition:

Possible complications/medications:

Expected outcomes (functional improvement, symptom relief, wellness):

Typical activities of daily living (affected by condition?):

Occupation (affected by condition?):

Are you seeking insurance reimbursement? Yes ☐ No ☐
Car collision/personal injury? ________________________
On-the-job injury? ________________________
Private health insurance? ________________________
Do you have a physician referral with diagnosis codes? ________________________
Let clients know if you provide billing services, and if so, for what types of claims, or if you will simply provide receipts and/or
copies of records for them to submit for reimbursement. Let clients know a physician referral demonstrating medical
necessity is required for insurance reimbursement/health savings account reimbursement regardless of who submits bills.
Best times for massage: ________________________
Associated Bodywork & Massage Professionals
Practitioner/Clinic Name: ________ Screening Questionnaire
Contact Information: ____________ (page 2 of 2)
Communication Checklist
Fees/forms of payment Cancellation/No-show policy
Late arrival policy Confidentiality
Parking/directions Work setting
Clothing/shiatsu Modesty/Nonsexual/draping
Food/drugs/alcohol Oils/lotions/allergies
COVID-19 Related Questions

  1. Have you had a fever in the last 24 hours of 100°F or above? Yes ☐ No ☐
  2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
    Yes ☐ No ☐
  3. Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or
    lesions? Yes ☐ No ☐
  4. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has
    coronavirus-type symptoms? Yes ☐ No ☐
    Inform clients of any new protocols you’ve implemented as a result of COVID-19, including directions about arrival,
    wearing a mask during the session, and getting set up for contactless payment beforehand.
    Do you have special needs I should prepare for:

Do you have any questions or concerns:

If out-call, ask for directions, parking, or special instructions:

Packet Checklist
o Health Information
o Health Status Report
o Billing Information
o Directions/map
Date sent __
Additional Notes