Pre-appointment Covid-19 symptom check

Pre-appointment Covid-19 symptom check
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Date of appointment

Month Day Year
Date
Testing
Have you had a Covid-19 test? If yes, when? *

Yes No
Date of test

Month Day Year
Date
If it was a positive result, has the isolation period expired?

Yes No
Do you still have symptoms?

Yes No
Symptoms

Are you experiencing any of the following? *

Yes

A new or persistent cough?

A fever?

A reduced sense of taste or smell?

Shortness of breath?

Have you been in contact with anyone with covid-19 symptoms or been living in a household with someone who is self-isolating due to covid-19 symptoms within the last two weeks?

If yes, please isolate for 14 days
Current health issues

Extra precautions with PPE may be required
Have you recently been hospitalised? *

Yes No
If so, why?

Do you have any of the following conditions? *

Yes

High blood pressure or other heart condition

Diabetes

Cancer

Respiratory condition

Are you pregnant?

Are you aged over 70?

If you have previously contracted coronavirus, are you experiencing post covid-19 circulatory complications (deep vein thrombosis, micro-embolisms, stroke symptoms or pulmonary embolism)?

Exposure to covid-19? (Extra precautions with PPE may be required) Are you..... *

Yes

An NHS front line worker

A carer - home or care home

Sheilding a vulnerable adult

Any other information.....

(not covid-19 related)
Have there been any changes to your health and wellbeing since your last appointment? *

Yes No
If yes, please give details here. Also, if you are having a treatment using essential oils, it is always helpful if you let me know how you are feeling and how you would like to feel after your appointment so that I can select oils to suit your needs. If there are any essential oils you particularly love or dislike, please let me know.
Would you like to speak to me prior to your appointment to discuss any particular needs? If yes, I will call you before your appointment. *

Yes No
I am taking all measures possible to keep my business covid-19 free to protect my clients and myself.

Please contact me immediately if anyone in your household develops covid-19 within 7 days of your treatment and please inform me on the day of treatment if any symptoms appear.

I will, of course, let you know if my current good health changes.
By siging here you confirm all the above information is correct and that you understand the infomation sent to you.

Your signature also confirms you give your informed consent to treatment.

If either I or someone I have been in contact with tests positive for covid-19 or I have been contacted by NHS Test & Trace I will inform you.
*

Clear
Date

Month Day Year
Date
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Pre-appointment Covid-19 symptom check

Testing

Symptoms

If yes, please isolate for 14 days

Current health issues

Any other information.....