DO Hypnosis Kent- Covid 19 Risk Assessment
Please fill out this risk assessment prior to your visit to help everyone stay safe and healthy! Thank you for taking the time to answer these questions
Name
First Name
Last Name
1. New onset of cough?
Yes
No
2. Worsening Chronic Cough?
Yes
No
3. Sore throat?
Yes
No
4. Shortness of breath?
Yes
No
5. Difficulty Breathing?
Yes
No
6. Difficulty Breathing?
Yes
No
7. New loss or decrease in sense of taste or smell?
Yes
No
8. Runny nose?
Yes
No
9. Sneezing (not allergy related (not allergy related)
Yes
No
10. Hoarse voice
Yes
No
11. Nasal congestion
Yes
No
12. Diarrhea?
Yes
No
13. Chills?
Yes
No
14. Headache?
Yes
No
15. Unexplained fatique or malais?
Yes
No
16. Difficulty swallowing?
Yes
No
17. Nausea/vomiting?
Yes
No
18. Abdominal pain?
Yes
No
19. Have you travelled or have had close contact with anyone who has travelled in the past 14 days ?
Yes
No
20. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19?
Yes
No
20. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19?
Yes
No
21. High risk clients - Do you fall into any of the below categories? Please select the box if you answer yes to any of the questions below and specify which category you fall into. If you did answer yes to any of question 21 please contact me so that I can check up to date Government guidance at any given time and ensure that I am putting in all possible measures to keep you safe
Yes
No
Other
Have you had an organ transplant?
Are you having chemotherapy or antibody treatment for cancer, including immunotherapy?
Are you having an intense course of radiotherapy (radical radiotherapy) for lung cancer?
Are you having targeted cancer treatments that can affect the immune system?
Do you have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)?
Have you had a bone marrow or stem cell transplant in the past six months or are still taking immunosuppressant medicine. ?
Have you been told by a doctor that you have a severe lung condition such as cystic fibrosis, severe asthma, or severe Chronic Obstructive Pulmonary Disease (COPD) ?
Do you have a condition that means they you have a very high risk of getting infections such as Severe Combined Immunodeficiency (SCID) or sickle cell ?
Are you taking medicine that makes you much more likely to get infections (such as high doses of steroids)?
Do you have a serious heart condition and are pregnant?
Are you 70 or older ?
22. Moderate risk clients - Do you fall into any of the below categories? Please select the box if you answer yes to any of the questions below and specify which category you fall into. If you have answered yes to any of questions in 22 you fall into what the Government regards as moderate risk. At the time of writing this the Government guidelines are that people in the moderate risk group are advised to stay at home and social distance but they are not required to shield. For your own safety I would advise online Zoom sessions rather than Face to face sessions if you fall into this category. As I have advised that online sessions would be preferable for your own safety, and as I have ensured that all Government Guidance for PPE has been adhered to , If you still decide to go ahead with your face to face sessions, by signing this form you agree that DO Hypnosis Kent and any and all therapists working for Do Hypnosis Kent cannot be held responsible If you contract Covid-19 as a result of attending face to face session
Yes
No
Other
Are you 70 or older ?
Are you Pregnant?
Do you have a lung condition that's not severe such as asthma, COPD, emphysema or bronchitis?
Do you have chronic kidney disease?
Do you have diabetes?
Do you have liver disease (such as hepatitis)?
Do you have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)?
Do you have a condition that means that you have a high risk of getting infections?
Are you taking medicine that can affect the immune system (such as low doses of steroids)?
Are you very obese (a BMI of 40 or above)?
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
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