Home » Covid Questionnaire Name* First Last Please enter your E-mail address* Do you now or have you recently had a cough or fever?* Yes No If yes, Please choose date* MM slash DD slash YYYY Have you been out of the state of Vermont?* Yes No If yes, Please enter date* MM slash DD slash YYYY I have been vaccinated* Yes No Date of 1st vaccine* MM slash DD slash YYYY Date of 2nd vaccine MM slash DD slash YYYY Date of Vaccine booster MM slash DD slash YYYY Have you been tested for Covid?* Yes No If Yes were results Positive or Negative* Positive Negative Third Choice Have you had contact with friends closer than 6 feet social distancing?* Yes No If YES, Were they all vaccinated?* Yes No Do you have members of the household who are elder or Immune compromised?* Yes No How often do you shop weekly?* What's the longest period that you spend in a store?* Have you been to an indoor restaurant or coffee shop lately?* Requirements For Treatment: N95 mask or similar must be worn except while changing clothes or if you must lie face down on the treatment table. I will ask for feedback during the sessions. Please try to keep the answers brief. Also, please be sure to speak up if you have a question or concern during treatment. This can be very important. Please type your full name (For Filing purposes)* CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Skilled Neuromuscular and Craniosacral Therapy treatment can more easily and efficiently release the habituated patterns and provide relief. Contact me for a free phone consultation and appointment
