Covid 19 Questionnaire
The information provided on this form will be kept in the strictest confidence for centre use only and will assist the Natural Fitness and Therapies in providing the best service we can. We do not share your information with anyone.
Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back) *
Do you now, or have you recently had, a persistent dry cough? (coughing a lot for more than an hour or 3 or more coughing episodes in 24 hours or a worsening of a pre-existing cough) *
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms? *
Have you been told to stay home, self-isolate or self-quarantine? *
Do you have any other symptoms that may mean you have a Covid-19 infection? (loss of taste and smell, unusual fatigue or shortness of breath) *
People at high risk (clinically extremely vulnerable)* Please tick if any of the following apply to you:
People at moderate risk (clinically vulnerable). Please tick if any of the following apply to you (If you you tick from this list, you are at moderate risk from coronavirus and it is very important you follow the advice on social distancing.):
I declare that the information I have provided is correct to the best of my knowledge and I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. I consent to the practitioner retaining the details provided on this form for a period of 7 years from today. I further understand that if I am under 18 years of age, these records will be kept until I reach the age of 25 (7 years after reaching 18). *
Please type your name to confirm the above. *
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