Covid Questionnaire for Clients
Covid-19 Client questionnaire
We are under the obligation to ensure you, as our client as well as our staff remain safe.
The information you provide will be used strictly confidential and only for the purpose intended to.
First name __________________ Last Name _____________________
County __________________________ Postcode _____________________
Mobile __________________________ Date of Birth ___ / _____ / ________
Are you currently experiencing any symptoms associated with Covid-19? YES ____ NO _____
Are you experiencing any of the following (please tick if applicable)
____ Persistent dry cough ____ Headache ____ Fever
____ Joint or muscle pain ____ Loss of Smell/taste ____ Sore Throat
____ Difficulty breathing ____ Runny Nose ____ Chest pain
Is anyone in your household experiencing symptoms associated with Covid-19?
NO _____ YES _____ If YES you will need to self isolate for 14 days.
Have you been in contact with anyone experiencing Covid symptoms in the last 7 days?
NO _____ YES _____ If YES, you will need to get tested via the NHS
Have you returned from Travelling abroad in the last 14 days?
NO _____ YES _____ If YES – Where?
Have you previously been tested for Covid-19?
NO _____ YES _____ IF YES – Test outcome?
I herewith confirm that I will notify my therapist in case I develop Covid-19 symptoms and
I authorise the therapist to use my details for track and trace and to notify me or
anyone I have been in contact with in case of Covid-19 symptoms.
____ / ____ / ______ ________________ _________________
Date Signature Client Signature Therapist