covid 19 pre-appointment assessment form

Please complete the following form and press the 'Submit' button within 48 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 declare that the information I have provided is true and correct and I make this declaration conscientiously believing the same to be true. 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.

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

COVID 19 Pre-Appointment Assessment
  • Are you registered on any Test & Trace app?:
  • TESTING - Have you had a positive Covid-19 test in the past 14 days?:
  • Have you been in contact with anyone with either Covid-19, or Covid-19 symptoms, in the past 14 days?:
  • Has anyone in your household been in contact with anyone with either Covid-19, or Covid-19 symptoms in the past 14 days?:
  • IF YOUR ANSWER IS YES TO ANY OF THE ABOVE, THEN YOU SHOULD SELF-ISOLATE ACCORDING TO GOVERNMENT GUIDANCE AND CALL 111 FOR FURTHER ADVICE:
    • SYMPTOMS - Have you experienced any of the following in the last 7 days?:
      • High temperature or feeling feverish?:
      • Persistent cough or having breathing difficulties?:
      • Loss or change to sense of taste or smell?:
      • IF YOUR ANSWER IS YES TO ANY, THEN YOU SHOULD SELF-ISOLATE ACCORDING TO GOVERNMENT ADVICE AND CALL 111 FOR FURTHER GUIDANCE:
        • DO YOU HAVE ANY OF THE FOLLOWING HEALTH ISSUES?:
          • High blood pressure or other heart condition?:
          • Diabetes Type 1 or 2?:
          • Cancer - currently receiving any treatments?:
          • Lung condition - e.g. cystic fibrosis, COPD, severe asthma?:
          • Organ transplant in the last 6 months?:
          • Bone marrow or stem cell transplant in the last 6 months?:
          • Pregnant and with a serious heart condition?:
          • Suppressed immune system and susceptible to infections?:
          • Brain and/or nervous system conditions?:
          • Heart disease, diabetes, chronic kidney disease or liver disease?:
          • If you don't have any of health issues listed here, have you been told that you are clinically extremely vulnerable?:
          • ARE YOU?:
            • Over 70?:
            • Have a BMI of 40 or over?:
            • Of BAME heritage? (answering this question is entirely optional):
            • An NHS front line worker (please shower and change before your appointment)?:
            • A carer - either at home or in a care home?:
            • Shielding a vulnerable adult?:
            • Likely to have a companion with you?:
            • HAVE YOU?:
              • Arrived in the UK from abroad in the last 14 days?:

              • Been on holiday in the UK in the last 14 days?:
              • Date:
              Calico Pregnancy Massage Covid 19 Form