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Community College of Rhode Island

Therapeutic Massage Clinic Screening Questionnaire


The Student Massage Clinic does not transmit any health care information in electronic form outside the Clinic or by phone. The clinic does keep records for 5 years that are doubled locked in our building. The Community College of Rhode Island follows the federal HIPAA regulations and the privacy of health information about any individual is not used or disclosed.

Please provide the following information.

Personal Information
Medical Information Are you now, or have you ever, had problems with: (If treated less than six weeks ago, please bring a doctor's note.)

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Last Updated: 2/29/16