Please fill in this form before your appointment. Thank you!
1. Your full name:
2. To your knowledge, have you or any of your household members been in contact with someone who has tested positive for COVID-19 in the last 14 days, or been asked by Track and Trace to self-isolate?
3. Since your last treatment with us, have you or any household members tested positive for Covid-19? If yes, please state who has tested positive, date of the test results and whether the symptoms have resolved since.
4. Do you have symptoms of: extreme tiredness; unexplained muscle pains; persistent headache or feeling breathless?
5. Have you had a Covid-19 antibody test since your last treatment with us?
NoYes - with negative resultYes - with a positive result
6. Are you or any of your household members self-isolating because you are waiting for Covid-19 test results?
7. Have you or any of your household members returned from a non-except country in the last 14 days?
8. Are you or any household members experiencing any of the following: new continuous cough; temperature of 37.8 Celsius or higher; loss of or change in normal sense of taste or smell?
9. How would you rate your condition since your last appointment:
Considerably betterBetterThe sameWorseConsiderably worse
10. Any changes to your general health that we should know about?
11. What is your appointment type preference?
Face-to-FaceRemote video consultationNo preference
Disclaimer: Please note if your appointment was originally booked as face-to-face, it will go ahead unless we contact you. A face-to-face appointment is subject to the answers above and your preference. If your physiotherapist decides it is necessary to change the appointment type, we will be in touch with you on the day before your appointment.