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   _____________________
Address       ___________________________________________________________________
Town           ___________________________________________________________________
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