Coronavirus safety consultation

Questions	Yes	No
Have you had a Covid-19 test which gave a positive result?	Yes	No
Have you had a Covid-19 test which gave a negative result?	Yes	No
Are you experiencing any of the following: - fever, previous symptoms getting worse, cough, sore throat or runny nose? If any of the above, the advice is to self-isolate for 7 days	Yes	No
Are you experiencing any of the following: - chills or headache, painful swallowing, muscle & joint ache, fatigue or exhaustion, loss of taste or smell? If any of the above, the advice is to self-isolate for 7 days, and then taking a test will be necessary. Call 119	Yes	No
Are you experiencing shortness of breath, difficulty lying down, or other chest issues If any of the above, contact your GP or call 111	Yes	No
Have you been in contact with anyone with Covid-19 symptoms?	Yes	No
Have you had or are you now experiencing Covid-10 symptoms?	Yes	No
Have you recently been hospitalized?	Yes	No
Do you have any of the following health issues: - high blood pressure, heart condition, diabetes type 1 or 2, cancer, lung condition?	Yes	No
Do you have any medical conditions affecting the suitability of massage therapy?	Yes	No
Are you an NHS front line worker, a carer at home or in a care-home, or shielding a vulnerable adult?	Yes	No
Are you pregnant, over 70 or allergic to cleaning products	Yes	No

I understand that the massage I receive is provided for the basis purpose of relaxation and relief of muscular tension.
If I experience any pain during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.
I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or qualified medical specialist for any mental or physical ailment of which I am aware.
I understand the massage therapists are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
I understand that massage should not be performed under certain medical conditions, and I have stated all my known medical conditions above.
I will let the therapist know before future treatments if my medical condition changes and understand that it is my responsibility to do so.
I acknowledge that should I be late for my appointment the therapist has the right to alter the length of my massage to suit the needs of the office schedule.
I also understand that any inappropriate or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

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