Covid Screening

Welcome to your Covid Screening

Client name:
Appointment date:

Have you had a high temperature? (this can mean feeling hot to touch on your chest and back - you do not need to measure your temperature)

Have you had a new continuous cough? (this means coughing a lot for more than an hour or three or more coughing episodes in 24 hours - if you usually have a cough, it may be worse than usual)

Have you lost sensations of taste or smell?

Have you had close contact (under 2 metres) with anyone with a confirmed Covid-19 diagnosis or someone exhibiting the above 3 symptoms in the last 14 days?

Have you recently travelled abroad and/or been instructed by the government to quarantine?

Have you been contacted by the government or NHS and told to self-isolate for any reason?

Do you fall under the clinically vulnerable category? 

Clinically vulnerable people are those who are:

  • aged 70 or older (regardless of medical conditions)
  • under 70 with an underlying health condition listed below (that is, anyone instructed to get a flu jab each year on medical grounds):
  • chronic (long-term) mild to moderate respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
  • chronic heart disease, such as heart failure
  • chronic kidney disease
  • chronic liver disease, such as hepatitis
  • chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), or cerebral palsy
  • diabetes
  • a weakened immune system as the result of certain conditions or medicines they are taking (such as steroid tablets)
  • being seriously overweight (a body mass index (BMI) of 40 or above)
  • pregnant women

 

Do you live with someone who is in the clinically vulnerable category?

If you have answered YES to any of the above questions, do you consent to going ahead with this session or would you prefer to re-schedule? If you go ahead, you hereby indemnify me (Jane Collison) from any liability whatsoever.

Covid19 Client Checklist & Consent

Please complete this new anti-infection pre-appointment questionnaire. Thank you!

Do you or anyone in your household have any symptoms of Covid19? In particular, a fever, a cough, loss/change in sense of smell/taste. If you answer YES to this question, please contact me to either make your session a remote one or to re-schedule. (All cancellation fees have been suspended for now.)
Do you undertake to let me know if you develop any symptoms within 7 days of your appointment with me?
Do you hereby give consent for me to give your contact details to the NHS Track & Trace service if I am requested to do so?
Are you ok with me touching your hands, face and head? (I will wash my hands thoroughly before we start and wear cotton gloves if you want me to.)
Do you want me to wear gloves when touching you? I am not required to do so and I have found that I cannot sense your body's energy when wearing them. You are, of course, welcome to bring/wear your own gloves (but it may alter the muscle response - we can check this). NB: I am offering to wear clean cotton gloves, not plastic.
Do you consent to me wearing a face visor/shield only? I have found that I cannot work in a mask - and I am not required to wear one. You are, of course, welcome to bring/wear your own mask (but it may alter the muscle response - we can check this).
Are you willing/able to pay by bank transfer on the day of your appointment (not before, in case you/I need to cancel)? My bank details are: Lloyds, sort code: 30-99-56, Account: 43480760. (You can also pay by card or cash at your appointment.)
When you arrive, I have to ask you if you can answer YES to any of the following 8 questions. Do you foresee any likelihood of you answering YES?

In the last seven days: 1. Have you had a high temperature? (this can mean feeling hot to touch on your chest and back - you do not need to measure your temperature) 2. Have you had a new continuous cough? (this means coughing a lot for more than an hour or three or more coughing episodes in 24 hours - if you usually have a cough, it may be worse than usual) 3. Have you lost sensations of taste or smell? 4. Have you had close contact (under 2 metres) with anyone with a confirmed Covid-19 diagnosis or someone exhibiting the above 3 symptoms in the last 14 days? 5. Have you recently travelled abroad and/or been instructed by the government to quarantine? 6. Have you been contacted by the government or NHS and told to self-isolate for any reason? 7. Do you fall under the clinically vulnerable category or the clinically extremely vulnerable category? 8. Do you live with someone who is in either the clinically vulnerable category or the clinically extremely vulnerable category? 

Please enter your name and today's date as proof that you accept seeing me for a Kinesiology session on the above basis. Thank you! I really look forward to seeing you and helping you with your health now we've got all that out of the way!  Jane