Cold, Flu and COVID Screening - Poise Sport & Remedial Massage

Name *

First

Last

Date of your appointment *

Do you or any member of your household currently have a High Temperature? *

If you are not able to take you temperature you can check if you feel hot to touch on your chest or back (this can indicate you have a temperature)

Do you, or any member of your household have a new, continuous cough? *

This means coughing a lot for 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)

Do you, or any member of your household, currently have a loss or change to your sense of smell or taste? *

This means you've noticed you cannot smell or taste anything, or things smell or taste different to usual.

Do you, or any member of your household, currently have a sore throat? *

Do you have symptoms of a common cold or flu? *

Are you subject to a positive Lateral Flow or PCR test?

Although you are no longer required to self isolate we will need to re-arrange your massage appointment if you are still showing a positive lateral flow or PCR test result.

Have you been in recent close contact with someone who has been tested positive for COVID?

Have you had the COVID vaccine in the last 48 hours? *

People react differently to the COVID vaccine. For this reason, no treatment can be undertaken within 48 hours of receiving the vaccine

Have you been diagnosed with Post-COVID 19 (Long COVID)?

If you have been diagnosed with long Covid, we will discuss how to adapt your massage to assist you in your recovery.

Consent Declaration *

The information I have given in this form is honest, accurate and correct to the best of my knowledge. I have had the opportunity to ask all the questions about its consent and all of my questions have been answered to my satisfaction. I appreciate that although all reasonable steps to reduce risk of infections have been taken, including screening potential COVID-19 cases and undertaking increased hygiene and distancing protocols there may still be a risk of infection from face-to-face treatment. I knowingly and willingly consent for face-to-face appointments to take place.

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