Aberdeen

Willowbank House, Willowbank Road, Aberdeen, AB11 6YG

01224 332358

Mobile: 07964081597

Banchory

23 Burnett Road, Banchory, AB31 5SB

01330 825163

Mobile: 07964081597

COVID PRE-ASSESSMENT SCREENING

In Balance Physiotherapy Aberdeen Balance Clinic

Personal Details
Name:
Address:
Telephone :

About Me:

I confirm that I have not had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat.

Yes  No 



I confirm that I am not in the clinically extremely vulnerable category and therefore advised to shield at home by the government.

Yes  No 



I confirm that to the best of my knowledge, I have not been in close contact with anyone with confirmed COVID-19 in the last 14 days.

Yes  No 



I understand that coronavirus may not cause symptoms in some people and is currently causing a pandemic which means healthcare services are required to operate differently.

Yes  No 



I confirm I have been made aware of physiotherapy guidelines that require a telephone/video triage appointment to be conducted before I can attend in person.

Yes  No 



About my Visit:

I confirm I am aware of the clinic’s requirement for social distancing in the clinic.

Yes  No 



I confirm I am aware of the clinic’s requirement for hand decontamination in the clinic:

Yes  No 



I confirm I am aware that the clinic might require me to wear a face-covering whilst inside the clinic (exemptions may apply):

Yes  No 



I confirm I have been told about the cleaning of the clinic room before/after my attendance:

Yes  No 



I confirm I am aware of the clinic’s requirement for contactless payment

Yes  No 



I understand that my physiotherapist is required to wear PPE as set by Public Health authorities during my appointment and this is not optional for them.

Yes  No 



About my Clinician:

They have confirmed they have not had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat.

Yes  No 



They have confirmed that to the best of their knowledge, they have not been in close contact with anyone with confirmed COVID-19 in the last 14 days.

Yes  No 



They have discussed with me the reasons why my clinical need for healthcare cannot be met by a telephone/video consultation.

Yes  No 



I have had the opportunity to ask all the questions I wish to, and all of my questions have been answered to my satisfaction. Use space below to record details:


I agree to attend a face to face appointment during the COVID-19 pandemic.

Yes  No 



Signed Patient ………………………………………………………………………

OR [delete as applicable]


Signature of person with parental responsibility / person legally entitled to sign on behalf of a person who lacks capacity ………………………………………………………………………………………………

Signed Therapist………………………………………………………………………

Date: …………………

CONTACT US


Aberdeen: 01224 332358

Banchory: 01330 825163

Mobile: 07964081597

Find Us

OUR CLINICS


In Balance Physiotherapy, Aberdeen & Aberdeen Balance Clinic: Willowbank House, Willowbank Road, Aberdeen, AB11 6YG


In Balance Physiotherapy, Banchory

23 Burnett Road, Banchory, AB31 5SB

HCPC & CSP, CHARTERED PHYSIOTHERAPISTS

HCPC & CSP, CHARTERED PHYSIOTHERAPISTS