COVID Screening Questionnaire for New Patients

Please complete the form below no sooner than two days before your appointment. 

COVID Screening Questionnaire for new patients
Have you suffered any symptoms of Covid 19 in the past 10 days including (a new cough, a high temperature, loss of taste of smell, or sore throat)?
Has anyone in your household been diagnosed with Covid 19 or had Covid 19 symptoms in the past 10 days?
Have you been in close contact with anyone else with Covid 19, in the past 10 days?
If your physiotherapist is contacted by test and trace, do you consent to your details being given as a contact?
Have you recently travelled back from a country that requires you to quarantine or take COVID test?