Home » Covid Questionnaire Order Number Please enter your eMail address * Do you now or have you recently had a cough or fever? * Yes No If yes, Please choose date Have you been out of the state of Vermont * Yes No If yes, Please enter date Have you been tested for Covid? * Yes No If Yes were results Positive or Negitive Positive Negitive How many times do you go shopping per week * 1 2 3 4 or greater Do you always wear a mask * yes No Have you had contact with friends closer than 6 feet social distancing? * Yes No Do you have members of the household who are elder or Immune compromised? * Yes No Requirements For Treatment: Multi-layered cloth mask must be worn except while changing clothes or if you must lie face down on the treatment table. Please wait in your car until I come outside to alert you. Car color and type: * Primary discussions before and after our treatments will most often be outside in the air. 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) 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
