Covid-19 Screening & Consent

Please complete and submit within 48 hours of all clinic appointments

TESTING

Have you ever been tested for COVID-19 (antigen or antibody)?

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SYMPTOMS

Are you experiencing any of the following symptoms?

1. Severe breathing difficulties or chest pain - if yes, call 999)

2. Difficulty in waking or confusion (if yes, call 999)

3. Fever

4. Onset, or worsening of cough

5. Sore throat or runny nose

6. Chillls or headache

7. Pain swallowing

8. Muscle & joint ache (not relating to area of injury)

9. Fatigue or exhaustion

10. Loss of taste or smell

11. Shortness of breath or difficulty lying down due to chest issues

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If any of the above, advice is to self-isolate for 7 days, and call 119 for advice)​

ARE YOU CONSIDERED 'HIGH RISK'?

​If you are considered a high-risk client, it may not be possible to see you at this time but feel free to discuss this with me.  You may need to get clearance from your GP first.  This is the current list of ‘high risk’ conditions:

• Those shielding vulnerable family members, front-line NHS staff, carers and those who have been in contact with anyone suffering from COVID-19

• Anyone currently receiving treatment for cancer, suffering lung conditions or is post-operative

• Experiencing post COVID-19 circulatory complications (deep vein thrombosis, micro-embolisms, stroke symptoms or pulmonary embolism)

• Aged 70 years or above

• Pregnant

• Heart & respiratory conditions

• Suppressed immune systems

• Diabetes

• BMI over 39

If you answer YES to any of the above, please contact me to discuss or explain your particular situation.​

OTHER QUESIONS:

1. Have you been in close contact with a Covid-19 patient in the last 14 days?

2. Have you recently been hospitalised (in the last 4 weeks)?

3. In the last 14 days, have you traveled abroad or to an area in the UK that has been in local Lockdown?

4. Allergic to specific cleaning products?

DECLARATION

I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.
If either I or someone I have been in contact with tests positive for Covid-19 or have been contacted by NHS Test & Trace I will inform you.

By submitting this form, you agree to the collection of data in this way.

Thanks for submitting!