Covid-19 Client Screening Form
Thank you for taking the time to answer these questions. The following questions are to protect me, you and all our loved ones
Name
*
First Name
Last Name
1. Have you or anyone in your household been diagnosed with Covid-19 in the last 14 days?
*
Yes
No
2. Have you or anyone in your household shown any of the following symptoms in the last 14 days: cough, raised temperature, headaches, shortness of breath, fatigue, rashes on body or feet, loss of or changes to taste or smell, unusual aching or muscles and/or joints, sore throat, diarrhoea or vomiting? Please give details:
3. Have you or anyone in your family been advised by the government as being clinically vulnerable with a need to shield?
*
Yes
No
4. If you have been advised to shield, is your shielding still in place?
*
Yes
No
Not applicable
5. Have you knowingly been exposed to anyone diagnosed with COVID 19 within the last 10 days?
*
Yes
No
*
I understand that with rapidly changing understanding of the virus Helena Argüelles is taking all necessary and advisable precaution and there is no 100% guarantee that we are protected from the virus
*
I have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 10 days
*
I agree to inform Helena Argüelles if I, or someone I live with, begin to show symptoms within 10 days after my appointment
*
I have read Helena Argüelles' Covid-19 Safeguarding Policy which has been sent to me by email
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