Health Screening Questionaire

Your Name(required)

Email(required)

Phone(required)

Appointment Date(required)

Have you visited any other countries other than Ireland and Northern Ireland in the past 14 days?(required)

yes no

Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?(required)

yes no

Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?(required)

yes no

Are you a close contact with a person who is a confirmed or suspected case ofCOVID-19 in the past 14 days (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day)?(required)

yes no

Have you been advised by a doctor to self-isolate at this time?(required)

yes no

Have you been advised by a doctor to cocoon at this time??(required)

yes no

Do you consider yourself to be in the category of people at higher risk from coronavirus? If you are unsure whether or not you are in an at-risk category, please visit https://www2.hse.ie/ conditions/coronavirus/people-at-higher-risk.htm(required)

yes no

If your situation changes after you complete and submit this form you agree to inform Cindy on 087 6710280.(required)

yes no

Please enter any other information you feel is relevant.

The information requested here is used for pre-screening purposes as well as contact tracing requirements.

Ekko Therapies

Let your body do the talking and transform stress and pain through Shiatsu, Massage and Reflexology