Corona Virus Screening

Please could you complete the following initital Coronavirus screening form.

I will need to keep the information you send in line with General Data Protection Regulation (“GDPR”).

From the 3rd December 2020 we are fully open for treatments again.

We are structuring sessions for you to have the best (and safest) experience under the current restrictions. You will need to complete the Corona Virus Screening form. Virtual sessions are still available.

Stay safe and sane. With warm regards, Regina

Current Covid-19 symptoms

These are the most common Covid-19 symptoms.

Loss or change to your sense of smell or taste – this means you have noticed you cannot smell or taste anything, or things smell or taste different to normal.
High temperature – this means you feel hot to touch on your chest or back.
New, continuous cough – this means coughing for a lot more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual).

Please cancel if you have Covid-19 symptoms.

Initial Covid-19 screening and risk factors

Please note that all fields followed by an asterisk must be filled in.

Have you had a test for Covid-19?*

	no
	yes, within last two weeks and tested negative
	yes, within last two weeks and tested positive
	yes, tested negative longer than two weeks ago
	yes, tested positive longer than two weeks ago

Have you had Covid-19?
If yes, please describe: when, severity, post-viral effects

Are you at moderate risk from coronavirus??
Please tick: You ... *

	are 70 or older
	are pregnant
	have a lung condition that is not severe (such as asthma, COPD, emphysema, or bronchitis)
	have heart disease (such as heart failure)
	have diabetes
	have chronic kidney disease
	have liver disease (such as hepatitis)
	have a condition affecting the brain or nerves (such as Parkinson's or motor neurone disease, multiple sclerosis, or cerebral palsy)
	have a condition that means they have a high risk of getting infections
	are taking medicine that can affect the immune system (such as low doses of steroids)
	are very obese (a BMI of 40 or above)
	have none of the above

Are you at high risk (clinically extremely vulnerable) from coronavirus?
Please tick: You ...*

	have had an organ transplant
	are having chemotherapy or antibody treatment for cancer, including immunotherapy
	are having an intense course of radiotherapy (radical radiotherapy) for lung cancer
	are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)
	have blood or bone marrow cancer (such as leukaemia, lymphoma, or myeloma)
	have had a bone marrow or stem cell transplant in the past 6 months or are still taking immunosuppressant medicine
	have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma, or severe COPD)
	have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell)
	are taking medicine that makes them much more likely to get infections (such as high doses of steroids or immunosuppressant medicine)
	have a serious heart condition and are pregnant
	none of the above

If have a risk factor (even if it not listed above), please provide details.

Is anyone you live with in a risk group?*

	no
	yes, moderate risk
	yes, high risk

Are you

	a healthcare worker or first-responder (including on a voluntary basis)?
	working in laboratory with direct exposure to biological specimens that contain Covid-19?
	currently (mostly) shielding?

By sending this form you*

	consent to having treatment
	are aware of the risks
	currently do not test positive for Covid-19
	do not have corona virus symptoms (or any other potentially contagious condition)
	will cancel treatment if you have Covid-19
	will inform Touching Well should you develop Covid-19 within a week of treatment
	will wear a face covering (unless exempt)

	understand that the treatment is no substitute for medical advice
	will let the practitioner know immediately if I feel uncomfortable at any time during the session
	understand that if I cancel a session less than 48 hours prior to the start of the session I am liable for the full fee, unless negotiated otherwise and/or is related to Covid.