COVID-19 Screening Questionnaire

1) Have you had any of the following symptoms in the last 10 days*

	Yes	No
Cough
Shortness of breath of difficulty breathing
Temperature of over 38C or feeling feverish
Sore throat
Shortness of breath
Flu like symptoms such as fatigue, headache
Nausea or Diarrhoea
Chills or Shivering
Muscle Pain or Rash
New loss of taste or smell

2) In the last 14 days have you:*

	Yes	No
Been in contact with someone who was diagnosed or had symptoms of COVID-19?
Had a COVID-19 test?
Was it positive?

Consent for treatment
I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. Clinic's Covid-19 policy is available here.
I give my consent to receive treatment from this practitioner.
If you are signing on behalf of the patient, or if the patient is a minor please state their name blanks . Please confirm your relationship to the patient blank
Signature*

Clear
Date*

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Date
Should be Empty:

COVID 19 Screening Checklist