Exmoor Osteopathy Ltd Patient Screening Questionnaire for COVID – 19
Please complete this form
Name *
Date of Birth *
Date Form Completed *
If any of the answers to these questions change between the time of filling in this form, and the time of my appointment, I will inform the practitioner *
Do you have any of the following symptoms:
New persistent cough *
New Shortness of breath or difficulty breathing *
Raised temperature/fever (over 37.8) *
New Headaches *
New Fatigue or tiredness *
Loss or change of smell/taste *
Nausea, vomiting or diarrhoea *
New rash anywhere on your body *
Is anyone in your household suffering from these symptoms? *
Have you been tested or due to be tested for COVID- 19? *
Have you been in close contact with anyone exhibiting symptoms of COVID-19? *
Have you travelled anywhere abroad in the last 14 days? *
If yes, where, and when did you return?
Have you been classified as belonging to the vulnerable category i.e:
Did you receive a letter from the NHS asking you to self-isolate for 12 weeks from March 23rd? *
Have you had an organ transplant? *
Are you undergoing cancer treatment? *
Have you had a bone marrow or stem cell transplant within the last 6 months? *
Do you have a severe respiratory condition? *
Is your immune system compromised in any other way? *
IF YES TO ANY - We will be in touch with you to discuss your treatment options
Are you in the “Moderate Risk” group; do you fall into any of these categories?
Are you aged over 70? *
Are you pregnant? *
If yes, how far into your pregnancy are you?
If yes, do you have a heart condition? *
Do you have a less severe respiratory condition? *
Do you have a disease of the heart, liver or kidney? *
Are you diabetic? *
Do you have a neurological disease? *
Do you have a condition, or medication, that makes you at high risk of developing infections? *
Do you have a very high BMI (kg/m2 of over 40) *
IF YES TO ANY - We will be in touch with you to discuss your treatment options
To determine urgency of care:
Does your pain ever exceed 6/10 *
Does your complaint affect your ability to work (or would it if you were working) *
If I decline to treat you, would you use NHS services, or try to “live with it” for longer *
RISK: Although we screen every patient for COVID-19, there is obviously an increased risk with a face-to-face consultation that I have to make you aware of - are you happy to take on that risk? *
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