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COVID 19 Health Screening Questionnaire
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Tim Humphries BSc(Hons) MCSP MAACP, Chartered Physiotherapist
TIPTREE PHYSIOTHERAPY CLINIC WEST MERSEA PHYSIOTHERAPY CLINIC
Forename/Surname
*
Your answer
Address including postcode
*
Your answer
Phone number: Landline/Mobile
*
Your answer
Date of Birth
*
Your answer
Please select whether you have developed any of these symptoms in the last 10 days
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No symptoms
New, persistent cough
High temperature
Loss or change to taste and/or smell
Required
If you selected any of the above symptoms you must cancel your appointment, self isolate for 10 days and arrange a test for Covid-19.
Has anyone else in your household started displaying any of the above symptoms within the last 14 days?
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Yes
No
If you answered yes please cancel the appointment and re book in 14 days provided you stay well.
I can confirm that I consent for my details to be shared with the NHS Test and Trace Service ONLY IF requested to try to identify who may be at risk of coronavirus.
*
Yes
No
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