Coronavirus

Gold Standard Physiotherapy

COVID-19 Self-Assessment Form
Name
Date of Birth

Month Day Year
Date
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *

Yes No
Are you a close contact of person who is confirmed or is a suspected case of COVID-19 in the past 14 days? (i.e. less than two metres apart for more than 15 minutes accumulative in 1 day) *

Yes No
Are you experiencing symptoms now or in the last 14 days (cough, shortness of breath, fever, high temperature, sore throat, runny nose or flu like symptoms)? *

Yes No
Please specify details of the symptoms
Have you been advised by a doctor to cocoon at this time? *

Yes No
Have you been in a hospital or healthcare setting in the past 14 days? *

Yes No
By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.
Todays Date

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Date
Signature

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Gold Standard Physiotherapy