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ONLINE YOGA CLASSES
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Massage

Yoga-Mixed Levels (Virtual)
Accountability, Inspiration and Support for Your Wellness Goals!
Wednesday, Friday
1 hr

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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

What pressure do you prefer?

Heavy

Medium

Light

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

What is your chief complaint for seeking massage therapy?

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days