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COVID 19 Pre Appointment Assessment

Please complete the following form and press the 'Submit' button within 48 hours of your appointment. Many thanks


COVID 19 Pre-Appointment Assessment
  • TESTING - Have you had an Covid-19 antigen test (tests for Covid-19 on day of test)?:
  • If it was a positive result, has the isolation period expired?:
  • Do you still have symptoms?:
  • TESTING - Have you had an Covid-19 antibody test (tests for possible immunity to Covid-19 )?:
  • Are you registered with a Test & Trace app?:
  • SYMPTOMS - Are you currently experiencing severe breathing difficulties or chest pain? :
  • Do you currently have difficulty in waking or confusion?:
    • OTHER SYMPTOMS: Do you currently have any of the following?:
      • Fever?:
      • Recent onset, or worsening of a cough?:
      • Sore throat or runny nose?:
      • Chills or headache?:
      • Pain swallowing?:
      • Muscle and joint ache (more than usual)?:
      • Fatigue or exhaustion?:
      • Loss of taste or smell?:
      • Shortness of breath or difficulty lying down due to chest issues?:
        • Have you been in contact with anyone with Covid-19 symptoms or who has tested positive for Covid-19?:
        • Have you recently been hospitalised?:
        • Do you have any of the following health issues?:
          • Diabetes Type 1:
          • Diabetes Type 2:
          • Cancer:
          • Any lung conditions?:
          • IF YOU HAVE HAD COVID-19 - Are you experiencing post Covid-19 circulatory complications?:

          • ARE YOU - An NHS frontline worker (please shower and change out of work clothes before your massage appointment)?:
          • ARE YOU - A carer either at home or in a care home?:
          • ARE YOU - Aged over 70?:
          • ARE YOU - shielding a vulnerable adult?:
          • ARE YOU - Pregnant? :
          • Would you prefer me to wear gloves for your massage? (more info at http://www.calicopregnancymassage.co.uk/covid-19.html#PPE):
          • There can be an increased risk of infection without glove use for your treatment. However if you choose for gloves not to be warn, please be assured:
            • that hands will be washed as per guidance for a minimum of 30 seconds immediately before and after your treatment. :
              • Are you allergic to specific cleaning products?:

              By submitting this form this is your declaration: I solemny and sincerely declare that the information I have provided is true and correct. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.

              If either I or someone I have been in contact with tests positive for Covid-19 or have been contacted by NHS Test & Trace I will inform you.

              I consent to my information being shared with NHS Test & Trace service should it be required. 

              Please note that all information submitted via this form is private and confidential and will not be shared with any individual other than your therapist, unless there is a legal requirement to share your information. Your personal information will be stored in accordance with GDPR requirements and you can request access to the information relating to you that is held by Calico Massage Therapy at any time. Calico's full Privacy Policy can be found here.


               Working in and around the Leeds and Bradford area and from a treatment room in Leeds, Calico Pregnancy Massage offers therapeutic antenatal and postnatal massage treatments. Please just contact me for a chat to find out more or to make an appointment. Privacy Policy.

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