Client Declaration (Covid-19)

Client details

All form fields are required.

Gender

1. Are you currently experiencing any symptoms of COVID-19?

2. Are you experiencing any of the following symptoms which have suddenly become apparent (tick those that apply)
Difficulty breathingChest PainLoss of Taste and/or smellFeverPersistent dry cough

Please note: if you are experiencing difficulty breathing or chest pain you should seek medical help as soon as possible. If you are experiencing and are worried about any of the other symptoms above you should call 111, self-isolate for 7 days and book a COVID-19 test.

3. Is anyone in your household experiencing any symptoms of COVID-19? YES NO If you have answered yes, you should self-isolate for 14 days.

4. Have you been in contact with anyone else with any COVID-19 symptoms in the last 7 days?

5. Have you experienced any symptoms since?

If you have answered Yes to questions 3 or 4, you should go online and obtain a test via the NHS website or call 119.

6. Are you or anyone in your family currently suffering from: (tick those that apply)
CancerBone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugsRespiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD)Rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency (SCID), homozygous sickle cell)On immunosuppression therapies sufficient to significantly increase risk of infection

7. Have you returned from travelling abroad in the last 14 days?

8. Have you ever had a test for COVID-19?

If yes, was it positive or negative?

If positive did you self-isolate, for how long and when did you start?


Please note that we are obliged to notify NHS track and trace if circumstances require such. if I/We report any symptoms among staff or clients, or are contacted by Track and Trace, we are legally obliged to provide them with your contact details and you may be contacted.

9. Do you promise to contact your therapist immediately if you or anyone in your household develops symptoms associated with COVID-19 within 7 days of your treatment?

10. If anything changes between now and your appointment time, do you promise to inform your therapist before your appointment date?

Thank you for your cooperation.