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:
had an organ transplant
having chemotherapy or antibody treatment for cancer, including immunotherapy
having an intense course of radiotherapy (radical radiotherapy) for lung cancer
having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)
have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)
had a bone marrow or stem cell transplant in the past 6 months, or still taking immunosuppressant medicine
told by a doctor that you have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)
have a condition that means you have a very high risk of getting infections (such as SCID or sickle cell)
Option taking medicine that makes you much more likely to get infections (such as high doses of steroids)9
pregnant and have a serious heart condition
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.):
70 or older
have a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis)
have heart disease (such as heart failure)
have liver disease (such as hepatitis)
have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)
have a condition that means you have a high risk of getting infections
Option 9taking medicine that can affect the immune system (such as low doses of steroids)
very obese (BMI of 40 or above)
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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This form was created inside of Natural Fitness & Therapy Centre.