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: …………………