covid 19 pre-appointment assessment form

Please complete the following form and press the 'Submit' button within 24 hours of your appointment. If you aren't sure of how to answer any of the questions, please don't hesitate to get in touch. Many thanks

By submitting this form this is your declaration: I have understood, read and completed this form truthfully to my knowledge and consent to having the massage therapy treatment. I hereby release the business and the therapist performing the service from any and all liability for any adverse reactions sustained as a result of the treatment, including unintentional exposure or harm due to Covid-19.

COVID 19 - Pre-Appointment Assessment

Full Name:*
TESTING - Have you had a positive Covid-19 test in the past 14 days?:
- Yes
- No
- I'm waiting for the results of a PCR test
Have you been in contact with anyone with either Covid-19, or Covid-19 symptoms, in the past 14 days?:
- Yes
- No
As far as you are aware has anyone in your household been in contact with anyone with either Covid-19, or Covid-19 symptoms in the past 14 days?:
- Yes
- No
IF YOUR ANSWER IS YES TO ANY OF THE ABOVE, THEN PLEASE FOLLOW CURRENT GOVERNMENT GUIDANCE :
SYMPTOMS - Have you experienced any of the following in the last 7 days?:
High temperature or feeling feverish?:
- Yes
- No
Persistent cough or having breathing difficulties?:
- Yes
- No
Loss or change to sense of taste or smell?:
- Yes
- No
Cold-like symptoms such as headache, runny nose, sneezing or sore throat?:
- Yes
- No
IF YOUR ANSWER IS YES TO ANY OF THESE PLEASE REFER TO THE MOST UP TO DATE GOVERNMENT GUIDANCE:
Have you had the Covid-19 Vaccination?:
- Yes - One dose
- Yes - Both doses
- Yes - Both doses plus Booster
- No
If you have had the Covid-19 Vaccination/s was the vaccination more than 2 weeks ago?:
- Yes
- No
- Not applicable
IF YOU HAVE HAD COVID-19 are you experiencing any post Covid-19 effects? If so, what are they? :
DO YOU HAVE ANY OF THE FOLLOWING HEALTH ISSUES?:
High blood pressure or other heart condition?:
- Yes
- No
Diabetes Type 1 or 2?:
- Yes
- No
Cancer - currently receiving any treatments?:
- Yes
- No
Lung condition - e.g. cystic fibrosis, COPD, severe asthma?:
- Yes
- No
Organ transplant in the last 6 months?:
- Yes
- No
Bone marrow or stem cell transplant in the last 6 months?:
- Yes
- No
Pregnant and with a serious heart condition?:
- Yes
- No
Suppressed immune system?:
- Yes
- No
Brain and/or nervous system conditions?:
- Yes
- No
Heart disease, diabetes, chronic kidney disease or liver disease?:
- Yes
- No
If you don't have any of health issues listed here, have you been told that you are clinically extremely vulnerable?:
- Yes
- No
ARE YOU?:
Over 70?:
- Yes
- No
Have a BMI of 40 or over?:
- Yes
- No
Of BAME heritage? (answering this question is entirely optional):
- Yes
- No
- Prefer not to say
An NHS front line worker (please shower and change before your appointment)?:
- Yes
- No
A carer - either at home or in a care home?:
- Yes
- No
Shielding a vulnerable adult?:
- Yes
- No
Likely to have a companion with you?:
- Yes
- No

Are you allergic to any cleaning products? Please specify:
SIGNED (please add full name and see full declaration at https://www.calicopregnancymassage.co.uk/covid-19-pre-appointment-assessment-form.html:
Date:

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.