Pre-Appointment COVID-19 Screening & Triage Form First Name * Last Name * Email * Date * Do you need to be accompanied * Yes No If Yes, name of accompanier: Your proposed accompanier must first call clinic to answer COVID and risk questions Triage Is your treatment for a painful condition? * Yes No If the condition is not painful, you CANNOT attend for treatment. COVID-19 Screening Have you tested positive for COVID-19 in the last 7 days? * Yes No Are you waiting for a COVID-19 test or the results? * Yes No Do you have any of the following symptoms: New continuous cough (this means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If a patient usually has a cough, it may be worse than usual) * Yes No High temperature of fever * Yes No Loss of, or change in, sense of smell or taste * Yes No Do you live with someone who has either tested positive for COVID-19 in the last 14 days? * Yes No If you answer YES to ANY these questions, you CANNOT come for treatment or accompany a person coming for treatment. General Health Are you suffering any common cold type symptoms or any infectious illness? * Yes No If you, answer YES to this question, you CANNOT come for treatment People at High Risk Have you received a letter from the NHS to advise you are high risk * Yes No If the answer is YES, then answer following questions If NO, then go to moderate risk. What are reasons for high risk? People at Moderate Risk Are 70 or older Yes No Do you have a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis) Yes No Do you have a heart disease (such as heart failure) Yes No Do you have Diabetes? Yes No Do you have chronic kidney disease Yes No Do you have liver disease (such as hepatitis) Yes No Do you have a condition affecting the brain or nerves (such as Parkinson’s disease, motor neurone disease, multiple sclerosis or cerebral palsy) Yes No Do you have a condition that means you have a high risk of getting infections? Yes No Are you taking medicine that can affect your immune system (such as low doses of steroids) Yes No Are you very obese (a BMI of 40 or above) Yes No Are you pregnant Yes No Please note that if you have received a letter from the NHS advising you are HIGH RISK, or you have answered YES to ANY of the above moderate risk questions, you cannot be booked for treatment without first having your case reviewed by a physiotherapist. Please submit your form and we will get back to you Submit