Covid19 Assessment form

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Please answer all questions and do let me know if anything changes prior to your appointment

Email *

Name *

Date of Birth *

YYYY

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?

Yes

Clear selection

Have you or a member of your household been in contact with anyone who has had Coronavirus within the past 14 days? *

Yes

Are you or any of your family self-isolating due to symptoms of the virus? *

Yes

Have you, or anyone in your household, shown any of the following symptoms in the last 7 days? *

A high temperature (above 37.8C)

A new persistent dry cough

A loss or change to your sense of taste or smell

A sore throat

Shortness of breath or breathing difficulties

A skin rash

None of the above

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? *

Yes

Have you or anyone in your household been advised by the Government as being clinically vulnerable and been asked to shield? *

Yes

Are you 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 *

Cancers such as leukaemia, lymphoma or myeloma who are at any stage of treatment

bone marrow or stem cell transplants in the last 6 months

a respiratory condition (including all cystic fibrosis, severe asthma and COPD)

diseases that significantly increase the risk of infections (such as sickle cell)

on immune suppression therapies sufficient to significantly increase risk of infection

women who are pregnant with significant heart disease, congenital or acquired

a weakened immune system

a heart condition

renal disorders

liver disorders

inflammatory bowel disease

diabetes

Please fill in the 'Vulnerability form' on my webste if you have answered yes to any of these questions

None of the above

Please fill in seperate (Vulnerability) form if you answer yes to any of the above conditions

Have you received a Covid 19 vaccine?

first Covid vaccine

both vaccines

No vaccine

Other:

Clear selection

Have you noticed any new rashes on your body or feet? *

Yes

Have you experienced any pain or cramping in your calves or legs? *

Yes

Have you been out of the country in the last seven days? If so please state where you have been *

Yes

Other:

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? *

Yes

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 *

Yes

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