Covid19 Assessment form
Please answer all questions and do let me know if anything changes prior to your appointment
Email address *
Name *
Date of Birth *
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Address *
Telephone number *
I am required to keep your name and telephone number for 21 days after treatment. Do you give permission for me to contact 'track and trace' and give ONLY your name and telephone number should a Covid19 outbreak occur?
Clear selection
Have you or a member of your household been in contact with anyone who has had Coronavirus within the past 14 days? *
Are you or any of your family self-isolating due to symptoms of the virus? *
Have you, or anyone in your household, shown any of the following symptoms in the last 7 days? *
Required
Have you been in close contact (less than 2 metres) with anyone in the last 14 days with the above symptoms or who has been diagnosed with Covid19? *
Have you or anyone in your household been advised by the Government as being clinically vulnerable and been asked to shield? *
Are you or anyone in your household currently suffering from or being treated for or have.. (If you are unsure please contact your GP for clarity.) Please fill in section 2 (Vulnerabilities) if you answer yes to any of these *
Please fill in seperate (Vulnerability) form if you answer yes to any of the above conditions
Have you noticed any new rashes on your body or feet? *
Have you experienced any pain or cramping in your calves or legs? *
Have you been out of the country in the last seven days? If so please state where you have been *
Do you promise to contact your therapist immediately if anything changes or you or anyone in your family develops symptoms associated with Covid19 prior to your treatment? *
I have discussed and understand the risks related to Covid 19 and close contact treatments. I wish to receive a Bowen treatment with you at your clinic *
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