Health Screening Questionaire

COVID-19 Client Declaration Form

To help prevent the spread of COVID-19 in the clinic and local community, we ask each patient/client to complete and sign this 24 hours before attending for treatment. On review of the form, I may contact you to ask you not to attend the clinic at this time and will discuss a suitable future appointment for your treatment.

N.B. Every question must be answered.

I have taken extra measures to safeguard all my clients prior to arrival. I kindly ask you to complete this declaration for the safety of you, other clients and the therapists attending this clinic.

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

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)

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

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)

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

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

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 conditions/coronavirus/people-at-higher-risk.htm(required)

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

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