OXSPINES OSTEOPATHY COVID SCREENING
Mandatory pre-screening documentation to keep everyone safe 07894 151654. Please return by email
Name *
Email *
Date of Birth *
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YYYY
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days ? * *
Have you had close contact or cared for someone who has or had a sore throat, fever, new continuous cough, respiratory illness, difficulty breathing but not had any testing, within the last 14 days? *
Clear selection
Have you experienced any cold or flu-like symptoms in the last 14 days ? ( To include fever, cough, sore throat, respiratory illness, difficulty breathing. ) *
Have you had an altered sensation or loss of Smell or Taste? * *
Required
THE CURRENT ADVICE FOR ANYBODY WITH THE FOLLOWING UNDERLYING CONDITIONS IS TO STAY AT HOME.
Are you a transplant recipient of a solid organ? * *
Are you over 70 years of age? *
Are you undergoing active chemotherapy or radical radiotherapy for lung cancer? * *
Are you undergoing active chemotherapy or radical radiotherapy for lung cancer? * *
Are you currently having immunotherapy or other continuing antibody treatments for cancer? * *
re you having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors? * *
Have you had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs ? *
Do you have severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD ? *
Do you have either SCID or homozygous sickle cell ? * *
Are you currently undertaking an immunosuppression therapy sufficient to significantly increase the risk of infection? *
Are you a pregnant woman with significant heart disease, either congenital or acquired? * *
Do you have diabetes? *
Are you obese with a BMI of 40 plus?*
Clear selection
Please tell me of any other condition not mentioned that you have *
I declare and confirm that to the best of my knowledge and belief that the 7 statements below are true and apply to me on this date. Please tick those that are true *
Thank you for completing the screening questionnaire. Oxspines osteopathy is doing the most stringent cleaning and screening protocols but has to advise you about the inherent risk of spreading or catching COVID by attending an appointment. By accepting a face to face appointment after completing the screening questionnaire, and after the 'on the day' telephone call, you have given the practitioner informed consent to treat and you understand the risk.
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