Health Screening Form

Clinic Reopening Important Information

It’s great we are now able to reopen but there will be some changes in how your appointment will proceed in order to keep you, myself and others safe.

New clients must complete the below online health screening form prior to attending their appointment.

A. Personal Details

1. First Name

3. Address

2. Last Name

4. Postcode

5. Email Address

6. Mobile Number / Phone Number

7. Occupation

B. Screening Questions

7. Could you be pregnant ?

Yes

7.a. If yes how many months?

C. COVID - 19
This Section must be completed to proceed with the treatment

1. Do you currently have any of the following conditions?

Fever

Fatigue

Dry cough

Sore throat

Loss of smell or taste

No to all

2. Have you or any family members of your household, currently have or have experienced COVID-19 symptoms within the last 14 days?

Yes

4. Have you travelled to another country in the last month?

Yes

4.a. If yes, where?

3. Have you or any family members of your household, been diagnosed with COVID-19 within the last 14 days?

Yes

5. Have you been in contact with anyone with Covid-19 symptoms? *

Yes

5.a. If yes, when provide details:

D. If you have had Covid-19:

1. Are you experiencing post Covid-19 circulatory complications (deep vein thrombosis, micro-embolisms, stroke symptoms or pulmonary embolism)?

Yes

E. Physical Activity

1. Do you take part in physical activity?

Yes

3. How many day(s) per week do you take part in an activity?

F. For your treatment

1. Reason for visit

anatomy

G. Pain Scoring

pain-score

1. Pain Score 1 - 10 state the number below (upper body)

2. Pain Score 1 - 10 state the number below (lowerbody)

Present complaint 1

Where is site of complaint? e.g Knee/back/Arm

Frequency of pain:e.g. constant, intermittent, gets better end of day etc

Constant

intermittent

sporadic

during the night

during the day

better end of day

Other

Present complaint 2

Where is site of complaint? e.g Knee/back/Arm

Frequency of pain:e.g. constant, intermittent, gets better end of day etc

Constant

intermittent

sporadic

during the night

during the day

better end of day

Other

Present complaint 3

Where is site of complaint? e.g Knee/back/Arm

Frequency of pain:e.g. constant, intermittent, gets better end of day etc

Constant

intermittent

sporadic

during the night

during the day

better end of day

Other

ONSET: if you have more than one complaint state in the boxes below...

WHEN: Indicate when injury/ medical condition/ pain / problem started

HOW: indicate how injury/medical condition/pain/ problem happened e.g playing football

Complaint 1. PROGRESSION: indicate if injury/medical condition/pain/problem

getting better

worse

same/stable

Other

Complaint 2. PROGRESSION: indicate if injury/medical condition/pain/problem

getting better

worse

same/stable

Other

Complaint 3. PROGRESSION: indicate if injury/medical condition/pain/problem

getting better

worse

same/stable

Other

ANY TREATMENT? Indicate if any treatment has been received and date of treatment e.g physiotherapy

DATE

Date

Declaration:

I, the undersigned have completed the form fully and accurately. I believe the details to be correct and consent to a massage/treatment with the therapist.

Please Print Name below

Lastly..we would like to keep in touch.

If you would like information on offers, discounts and information

Please select one of the below option to tell us the ways you would prefer to hear from us:

Yes please, I would like to receive communication by email.

Yes please, I would like to receive communication by phone.

Yes please, I would like to receive communication by text messages.

No, I do not want to receive any communication.

Health Screening Form

Clinic Reopening Important Information

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