Aligned For Life Chiropractic COVID-19 health questionnaire

It is essential that everyone attending the clinic for treatment completes this questionnaire to ensure that we reduce the transmission of COVID-19. If you are experiencing any symptoms of the virus please do not come to the clinic.

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* 1. Have you had a temperature above 37.8^oC in the past 2 weeks?

Yes

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* 2. Have you had a persistent cough in the past 2 weeks?

Yes

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* 3. Have you developed shortness of breath in the past 2 weeks?

Yes

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* 4. Have you visited a country in the past 2 weeks that requires you to self isolate?

Yes

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* 5. Do you work, or have you attended a facility that treats COVID-19 patients in the past 2 weeks?

Yes

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* 6. On arrival at the clinic you will have your temperature taken via non contact infra red thermometer, please confirm that you consent to this.

Yes

The team at Aligned For Life Chiropractic endeavour to uphold rigorous hygiene procedures and have protocols in place to attempt to reduce the spread of COVID-19. However, whilst we have attempted to reduce the risk of transmission of the virus we can not guarantee that there is no risk whilst attending your appointment.

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* 7. I understand that there is the risk of transmission of COVID-19 (coronavirus) whilst attending for my appointment at Aligned For Life Chiropractic and I am happy to receive treatment.

Yes

Your full name

If you develop any COVID-19 symptoms after completion of this questionnaire, are concerned about receiving treatment or feel that your symptoms have significantly improved you can cancel or reschedule your appointment without incurring any late cancellation fees.

Aligned For Life Chiropractic COVID-19 health questionnaire

Question Title

* 1. Have you had a temperature above 37.8oC in the past 2 weeks?

Question Title

* 2. Have you had a persistent cough in the past 2 weeks?

Question Title

* 3. Have you developed shortness of breath in the past 2 weeks?

Question Title

* 4. Have you visited a country in the past 2 weeks that requires you to self isolate?

Question Title

* 5. Do you work, or have you attended a facility that treats COVID-19 patients in the past 2 weeks?

Question Title

* 6. On arrival at the clinic you will have your temperature taken via non contact infra red thermometer, please confirm that you consent to this.

Question Title

* 7. I understand that there is the risk of transmission of COVID-19 (coronavirus) whilst attending for my appointment at Aligned For Life Chiropractic and I am happy to receive treatment.

* 1. Have you had a temperature above 37.8^oC in the past 2 weeks?