Screening Questionnaire during COVID-19 Pandemic
Compulsory for all patients prior to each face-to-face appointment, to minimise risk of infection to both patients and practitioners.

Chadstone Region Osteopathy is committed to ensuring the health and safety of each and every one of you.
Please read carefully the following questions and answer truthfully.

The first section screens your risk to our Osteopaths, and other patients who may come after you.
The second section screens our risk to you and those around you.

Upon submission, these answers will be reviewed by your osteopath prior to your appointment, and if there's any concern at all your osteopath will be in contact.

Thank you for your assistance in these challenging times.
Sign in to Google to save your progress. Learn more
Please enter your full name *
Have you had close contact with someone confirmed to have COVID-19? *
Have you been overseas in the last 14 days? *
Do you currently have a fever? *
Do you currently have a cough? (ANY cough, whether it be dry, productive, related to allergies or known pre-existing conditions) *
Do you have a sore throat, or any other signs of infection? *
How much exposure have you had to large numbers of people in the last 14 days? *
Are you over the age of 65? *
Do you have co-existing medical conditions that affect the lungs, heart, or immune system? *
Do you have close contact with older or vulnerable people who are at high risk of severe disease if they catch COVID-19? *
Are you happy to see your Osteopath, knowing that despite our best efforts at hygiene we cannot in a face-to-face consultation mitigate all risk of transmission? (Please review our current hygiene policy here - http://www.chadstoneregionosteo.com.au/covid-19-hygiene-procedures/ ) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Chadstone Region Osteopathy. Report Abuse
Google Forms