COVID 19 Guest Pre Screening Form - Layers Wellness & Spa

Client Name*

First Last

Phone*

Email*

Enter Email Confirm Email

Current temperature?*

Signs of a fever:
• in adults: 38°C (100.4°F) and above (oral temperature),
• in older adults: 37.8°C (100°F) and above (oral temperature),
• in children: 38°C (100.4°F) and above
• or 1.1°C above the person's usual value

Do you have a fever?*

Are you experiencing any of the following:*

• severe difficulty breathing (e.g., struggling for each breath, speaking in single words)
• severe chest pain
• having a very hard time waking up
• feeling confused
• loss of consciousness
• shortness of breath at rest
• inability to lie down because of difficulty breathing
• chronic health conditions that you are having difficulty managing because of your current respiratory illness

Do you have any of the following:*

• fever
• new onset of cough or worsening of chronic cough
• new or worsening shortness of breath
• new or worsening difficulty breathing
• sore throat
• runny nose
• chills
• painful swallowing
• stuffy nose
• headache
• muscle or joint ache
• feeling unwell, fatigue or severe exhaustion
• nausea, vomiting, diarrhea or unexplained loss of appetite
• loss of sense of smell or taste
• conjunctivitis (pink eye)

In the past 14 days, did you return from travel outside of Canada, or did you have close contact with someone who is confirmed as having COVID-19?*

If you answered yes to any of these questions you are absolutely contraindicated for massage or manual osteopathic treatment. You must call to cancel your appointment. You may need to self-isolate. It is recommended that you immediately contact your local health authority and follow their instructions.
You have a responsibility to help prevent the spread of COVID-19. There are steps you can take to protect yourself and others.
• Practice physical distancing. This is not the same as self-isolation. You do not need to remain indoors, but you do need to avoid being in close contact with people.
• Practice good hygiene: wash hands often, cover coughs and sneezes, and avoid touching your face.
• Monitor for COVID-19 symptoms: fever, cough, shortness of breath, sore throat or runny nose.
• If you do develop any COVID-19 symptoms, stay home and take this self-assessment again.

Confidential History In order to protect yourself, your therapist, health, and other, honest disclosure is essential.

COVID-19 Pre-Screening Form

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