Covid-19 Screening Questionnaire

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We all need to be committed to this – if you answer yes to any of the following questions, we ask that you re-schedule or call to discuss. We retain the right to refuse treatment if the declaration hasn’t been completed or if we feel there is a risk to staff or other clients.

Our staff are following the same guidelines for health and hygiene and we request that you do the same. This is to keep us all safe.
Thank you

IMPORTANT: Protocol for visiting the clinic.

When you come into the clinic for an appointment, we would appreciate, where possible, that you come alone, to enable us to maintain safe numbers in the waiting room. We do understand though if you need a support person with you. We will need their details for contact tracing, and they too will need to complete the questionnaire.

You will need to bring appropriate clothing for your appointment as we are unable to provide shorts or gowns. Please also bring any exercise bands you may use for your exercises as we are unable to share any equipment such as this between patients
To ensure contact is minimised (especially in the Reception waiting area), the providers have increased the length of time between clients and they are staggering these times. This is also to provide time for cleaning surfaces between patients. Chairs have been spaced further apart and standing space will also be provided.

We need you to use the hand sanitiser provided at the door when you enter the premises. You may be asked to confirm that you have done this.

Please scan in your visit using your Covid Tracer app or record your visit in the manual log provided.

Masks will be provided if necessary under MOH guidelines.

Thank you for your cooperation in keeping us all safe.

The Team At Te Aro Physiotherapy & Pilates

Email *

Date of Birth *

YYYY

Please select/tick YES or NO to the following questions *

Yes

Have you been in close contact with a person known to have the Covid-19 Virus?

Have you, or someone you have been in close contact with, been tested and are still awaiting results for COVID-19?

Have you or a close contact been asked to self-quarantine?

Do you or anyone you have been in close contact with, have any of the following: Fever or chills, Cough, Shortness of breath or difficulty breathing, Body aches, Headache, New loss of taste or smell or a Sore throat?

Are you over 70 or have compromised immune system?

have you been in or around Auckland?

Have you been at any of the locations of interest in Waikato, Christchurch or any other locations with cases?

Yes

Have you been in close contact with a person known to have the Covid-19 Virus?

Have you, or someone you have been in close contact with, been tested and are still awaiting results for COVID-19?

Have you or a close contact been asked to self-quarantine?

Are you over 70 or have compromised immune system?

have you been in or around Auckland?

Have you been at any of the locations of interest in Waikato, Christchurch or any other locations with cases?

Explain any YES answers in the box below

Signature: By typing your name in the box below, you acknowledge that the answers you provided are true and accurate to the best of your knowledge. *

Declaration Date / Today's date *

YYYY

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