Pre-screening triage questionnaire

Are you or any member of your household experiencing symptoms of COVID-19, such as a new continuous cough, a high temperature, a loss of, or a change in, your/their normal sense of taste or smell?

Have you or a member of your household been tested as positive for COVID-19?

Have you or any member in your household been in contact with someone with symptoms of COVID-19 in the last 14 days?

Screening for patient being in high risk group

Have you had an organ transplant?

Are you having chemotherapy or antibody treatment for cancer, including immunotherapy?

Are you having an intense course of radiotherapy (radical radiotherapy) for lung cancer?

Are you having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)?

Have you got blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)?

Have you had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine?

Have you been told by a doctor that you have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)?

Do you have a condition that means you have a very high risk of getting infections (such as SCID or sickle cell)?

Are you taking medicine that makes you much more likely to get infections (such as high doses of steroids or immunosuppressant medicine)?

Do you have a serious heart condition and are pregnant?

Do you have a household member or anyone that you come into close contact with who has any of the above?

Screening for patient being in moderate risk group

Are you 70 or older?

Are you pregnant?

Do you have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)?

Do you have heart disease (such as heart failure)?

Do you have diabetes?

Do you have chronic kidney disease?

Do you have liver disease (such as hepatitis)?

Do you have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)?

Do you have a condition that means you have a high risk of getting infections?

Are you taking medicine that can affect the immune system (such as low doses of steroids)?

Are you very obese (a BMI of 40 or above)?

Your Name:

Please confirm:

I agree to inform Dedham Osteopathy as soon as possible if I experience any symptoms of COVID-19 within two weeks of my appointment and agree to Track and Trace being able to contact me as required.

Consent to face to face treatment:

"I have read and understood the contents of the Practice Procedures, Infection Control and PPE and I am aware of the risks of a face to face appointment which given the close contact required means that there is an increased risk of transmission and exposure regarding COVID-19. I am also aware of the level of PPE that the practitioner and I will have to wear to mitigate the risk of transmission and the infection prevention and control measures that Dedham Osteopathy LTD has in place".

Please read our Practice Procedures/Infection Control and PPE

Please Confirm you have read:

Practice Procedures/Infection Control and PPE

Please Confirm:

I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration for client accountability believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration,

Please confirm:

I am not a robot