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. Please also consider family members who you live with, if they are considered vunerable you may not wish to expose them to increased risk by coming 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. Are you living with anyone who is self isolating?

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

As well as being unable to treat patients with COVID-19 or may have been in contact with people who have the virus; we can not also currently treat those patients who are catagorised as vulnerable or at risk. At risk or vulnerable groups are defined as:

Pregnant
pre-existing medical conditions such as diabetes
have a compromised immune system
currently undergoing or have recently had cancer treatment
on medication that compromises your immune system, e.g. steroids or chemotherapy.
received a letter from the government telling you to self isolate
Have a BMI greater than 40

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* 6. I confirm that I am not in any of the above risk groups

I do not fall into these risk catogories

I do fall into one/some of these risk catagories

If you do fall into a risk catagory what is the risk?

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* 7. 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

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* 8. How concerned/anxious are you about the current COVID-19 situation?

Very concerned

Not at all concerned

Clear

i We adjusted the number you entered based on the slider’s scale.

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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* 9. 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. Are you living with anyone who is self isolating?

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. I confirm that I am not in any of the above risk groups

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* 7. 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

* 8. How concerned/anxious are you about the current COVID-19 situation?

Question Title

* 9. 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?