Corona Virus Screening Form

COVID19 screening form.

Due to the infectious nature of COVID-19, this additional intake form must be completed before each Maria Pali Massage therapy session. (I will also complete the form before each clinic session) Please know that people with COVID-19 can be asymptomatic and still be contagious. There is no way to completely protect ourselves from this virus. However, please ask for the checklist of precautions to see how I am disinfecting the clinic between sessions. Also please answer these questions truthfully and do everything asked so we can do our best to protect each other. Thank you!
Full Name *

First Name Last Name
E mail *
Mobile number *
Do you have any of the following symptoms?: *

No symptoms severe shortness of breath or any difficulty breathing difficulty waking or confusion severe chest pain difficulty lying down due to chest pain
Do you have any of the following symptoms?: *

No symptoms Previous symptoms getting worse: cough fever Sore throat or runny nose (other than known allergies/hay fever)
Do you have any of the following symptoms?: *

No symptoms Painful swallowing Chills and headache (other than normal headaches/migraines) Loss of taste or smell Fatigue or exhaustion
Have you had or been in contact with anyone who has since tested positive for Covid 19? Details *
Have you been in contact with anyone in the last 14 days who is displaying Covid 19 symptoms? Details *
Have you been told to self isolate by the track and trace service *
Have you had Covid 19? *

yes no not sure
If you answered yes or not sure, to the above, please give details or say n/a *
What precautions have you taken to limit your exposure to the virus? *
Have you been tested for Covid 19? (Antigen – tests for Covid-19 on day of testing. Antibody – possible immunity) If yes, what type of test, when and what were the results? *
If it was a positive result, has the isolation period expired?
If yes, do you still have symptoms??
Your temperature will be taken and recorded using a non contact thermometer. Please confirm that you are happy for this to go ahead *

yes no
Are you registered with the Test and Trace app? *

yes no
Are you an NHS front line worker? *

yes no
Are you a carer – home or care home? *

yes no
Are you shielding a vulnerable adult? *

yes no
Are you a pregnant? *

yes no
Are you allergic to latex gloves or specific cleaning products? *

yes no
Have you been classed as an extremely vulnerable or vulnerable person by the NHS? *

yes no
Are you aged over 70? *

yes no
Therapists declaration
Client 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.
Date form completed *
Signature *
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COVID19 screening form.

Client Declaration