Self-Screening Assessment Questionnaire

Kelly Pearce, Registered Massage Therapist – please print and fill out, bring completed form with you to every massage appointment.

This form must be completed ONLY within 4-12 HOURS in advance to your Registered Massage Therapy
appointment with Kelly Pearce, RMT. All questions below must be answered truthfully.
By completing this form, you are helping lower the risk for COVID transmission, keeping the clinic, staff,
and other clients safe from the spread of COVID-19. If you do not complete this form or answer YES to
any of the questions your appointment will be rescheduled and no cancelation fees will be charged.

Thank you for your understanding.

Email address:

Name (First and Last)

Date of Appointment:

COVID-19 Symptoms include fever, chills, cough, shortness of breath, sore throat and painful
swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue, and loss of
appetite. People infected with COVID-19 may also experience gastrointestinal symptoms like diarrhea,
nausea, and vomiting a few days after the onset of the above symptoms.
1. Are you currently experiencing any of the following:
Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)?
Yes No

2. Are you experiencing any of the following:
Mild to moderate shortness of breath
Inability to lie down because of difficulty breathing
Chronic health conditions that you are having difficulty managing because of difficulty
Yes No

3. Are you experiencing cold, flu, or COVID-19 liked symptoms, even mild ones?
Yes No

4. Did you provide care or have close contact with a person with confirmed COVID-19?
Yes No

5. Have you or anyone in your household been tested for COVID-19 and are waiting for results?
Yes No

6. Have you traveled to any countries outside Canada (including the United States) within the last
14 days?
Yes No

Thank you for completing the self-screening questionnaire. If you answered yes to any of the above
questions, please contact Kelly Pearce, RMT to reschedule your RMT appointment, no cancellation
charges for the appointment.

Kelly Pearce, RMT
604 619 0232