COVID-19 Screening Form

COVID-19 Screening Form

Please ensure you answer all questions to the best of your knowledge. If you are unsure of any of the questions please contact Amy : bookings@amygornall.com or Phone 07904312861
Name

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

Area Code Phone Number
If you develop new symptoms inbetween filling in this form and your appointment time, you must inform us prior to your appointment.
Q1. Are you currently experiencing any COVID-19 symptoms? *

Yes No
Q2. Are you experiencing any of the following symptoms which have suddenly become apparent? Please select which apply or select N/A: *

Difficulty Breathing Chest Pain Loss of Taste or smell Fever Sore Throat Severe Lethargy Runny Nose N/A
Q3. Is anyone in your house hold experiencing any symptoms? *

Yes No
Q4. Have you been in contact with anyone else with any COVID-19 symptoms? *

Yes No
**If you answered Yes to Q3 or Q4 - you must self isolate for 14 days and obtain a test via the NHS or call 119.
Q5. Is anyone in your household shielding or in the vulnerable category? *

Yes No
Q6. Have you returned from travelling abroad in the last 14 days? *

Yes No
Q7. If you answered yes to Q6, please give details of where you travelled:
Q8. Have you had a test for COVID-19? *

Yes - Positive Yes - Negative No
Q9. If you tested positive, did you self-isolate? What was the date self isolation commenced?
Informed Concent: I declare to my knowledge the medical and personal information I have provided to be true. I give my consent for this information to be used as part of my consultations and treatment. I am fully aware of the physical risks involved within a treatment and rehab setting. I am also fully aware of the extra risks involved in attending face to face appointments during the Covid-19 crisis. I understand it is my responsibility as the client to update and inform of any changes to my health and medical conditions. *

Clear
I look forward to seeing you in clinic soon.

Amy

bookings@amygornall.com

07716433156
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