Pre-Treatment COVID Screening Survey
www.stressproject.org.uk

To keep everyone safe during the pandemic, Stress Project clients are required to complete this questionnaire prior to treatment. We assure you that the information you provide remains confidential unless we are legally bound to release it.
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Name *
Date *
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Are you currently experiencing any symptoms of COVID-19? *
Are you experiencing any of the following symptoms which have suddenly become apparent (tick those that apply)
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Is anyone in your household experiencing any symptoms of COVID19? If you have answered yes, you should self-isolate for 14 days. *
Have you been in contact with anyone else with any COVID-19 symptoms in the last 7 days? If you have answered Yes, you should go online and obtain a test via the NHS website or call 119 *
Have you experienced any symptoms since? If you have answered Yes, you should go online and obtain a test via the NHS website or call 119 *
Have you returned from travelling abroad in the last 14 days? *
If yes, when and where?
Have you ever had a test for COVID-19 YES /NO *
If yes, was it positive or negative? POSITIVE NEGATIVE
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If positive test result, did you self-isolate, YES NO
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For how long and when did you start the self-isolation?
Do you agree to contact your therapist immediately if you or anyone in your household develops symptoms associated with COVID-19 within 7 days of your treatment? *
If we report any symptoms among staff or clients, or are contacted by Track and Trace, we are legally obliged to provide them with your contact details and you may be contacted.
COVID-19 - Help us CONTROL THE SPREAD OF INFECTION* Wash your hands before and after your treatment. Wear a facemask and comfortable clothing. Keep your distance. Limit your contact with others. Bring your own throw & water bottle with you. Arrive on time, no early arrivals because we don't have a waiting area at the centre. Thank you.
Privacy Statement: Holloway Neighbourhood Group is GDPR compliant. Our full privacy statement can be found at www.stressproject.org.uk/privacy
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