Colourvita COVID-19 Questionnaire

Covid19 - Pre consultancy/treatment Questionnaire

For your safety and ours
Date

Month Day Year
Date
Name

First Name Last Name
Address

Street Address

Postcode
Phone Number
Please enter a valid phone number.
Time of Service
Treatment
Have you been strictly following the social distancing measures outlined by the government during COVID-19?

Yes No Sometimes
Have you, or has anyone you have been in close contact with, shown any signs or symptoms associated with coronavirus

Yes No Unsure Possibly
Are there any warning signs for mental health decline, depression, or anxiety? If yes, discuss treatment options or things to do at home to stay positive and active
Have you tested positive or had treatment for COVID-19 within the last two weeks?

Yes No Awaiting results Not had a test
Please confirm that you will check your temperature the morning of the appointment and advise us by telephone immediately if your temperature is higher than normal.
Are you considered a ‘High Risk’ or ‘Vulnerable’ person?

Yes No
Client Signature:

Clear
**Please note:

You will not be charged for appointments cancelled due to CV-19 – or the threat there-of

We reserve the right to take the temperatures of anyone attending an appointment.
Should be Empty:

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Covid19 - Pre consultancy/treatment Questionnaire