Health Screening Form

Coronavirus Screening and Consent form

At Ed Kirby Physiotherapy, the health of patients and staff is of paramount importance. To ensure this, please complete the Health Screening and consent forms below. 

If you answer yes to any of the statements below, please contact us before coming to your appointment.

Telephone: 01206 260408 Email: ed.kirby@edkirbyphysio.co.uk

 

• You have had an organ transplant
• You are having chemotherapy or antibody treatment for cancer, including immunotherapy
• You are having an intense course of radiotherapy (radical radiotherapy) for lung cancer
• You are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)
• You have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)
• You have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine
• You have a condition that means you are at risk of getting infections (such as SCI D or sickle cell)
• You are taking medicine that makes you more likely to get infections (such as steroids)
• You have a heart condition, such as heart failure
• You are pregnant
• You are 70 years of age or older
• You have diabetes
• You have chronic kidney disease
• You have a lung condition  (such as asthma, COPD, emphysema or bronchitis)
• You have liver disease (such as hepatitis)
• You have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)
• You are very obese (a BMI of 40 or above)

 

Symptoms

 

Do you currently have any coronavirus symptoms (below) or have you been in close contact with anyone who has tested positive for CoVid 19 within the past 14 days?

• A high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature)
• 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)
• 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 normal .

If you develop any of these symptom, please do not come to your appointment but contact NHS 111 for advice.

Please read the statements below and sign at the bottom.  If you have any questions regarding these statements please call the practice before signing the form and prior to attendance.

• The option of a remote consultation has been discussed with me prior to the appointment and I understand the reason why this has been deemed not appropriate
• I understand that there may be a need for close contact during the consultation. The risk of virus transmission will be reduced as much as reasonably possible by infection control measures such as hand washing, equipment cleaning and PPE usage. I am happy with this risk and have asked any questions I felt necessary before attending the appointment
• I am willing t o wear a face covering if appropriate during the consultation.
• I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscient i ously 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

Telephone: 01206 260408 Email: ed.kirby@edkirbyphysio.co.uk

Stansted GP Surgery, Castle Maltings, Stansted Mountfitchet, CM24 8XG