JDV REFLEXOLOGY COVID-19 RISK ASSESSMENT FORM

Please take a moment to read and complete this form within 24 hours of your treatment and select YES or NO to the following. Please contact Jacky if you have any further questions or concerns. Thank you.

Please let your practitioner know if anything below relates to you before you arrive for your treatment:

Please defer your treatment if you are :

Awaiting results from a COVID-19 test
If anyone in your household experiences Coronavirus symptoms you must cancel all appointments and put yourself in quarantine for 14 days, as per WHO advice.
You have recently tested positive for COVID-19 test
You have a high temperature, new continuous cough, or loss of change to your sense of smell or taste

Name

First NameLast Name

Have you tested positive or had treatment for Coronavirus?

YESNO

If you have had COVID-19, please seek verbal or written consent from your GP or consultant before treatment.

Do you or anyone in your household or under your care, or within your support bubble identify with either the shielding or high  risk categories?

YESNO

Does anyone in your household or support bubble have COVID-19, or symptoms of COVID-19?

YESNO

Have you been in close contact with anyone else in the past 14 days who has symptoms of COVID-19, or been contacted by the NHS Test and Trace service and told to self-isolate?

YESNO

If you answered YES to either of the last two questions , please defer from seeing your therapist until it is safe to do so.

Are you currently sheilding?

YESNO

If YES, please defer treatments until you are no longer shielding.

Have you been following social distancing measures?

YESNO

Are you aware of having a high temperature, or feeling unwell?

YESN0

Have you tested positive for Coronavirus antibodies

YESNO

Your therapist has carried out a full risk assessment. Be assured I am following all guidelines regarding safe and hygienic practices, infection control and the use of PPE issued by Public Health England and my professional governing body the Association of Reflexologists (AOR).

Please note that if your therapist develops signs and symptoms of COVID-19 and tests positive for the virus, your details may be shared with the NHS Test and Trace ( in line with GDPR/DATA PROTECTION), to help minimise the transmission of COVID-19 and support public health and safety.

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