I have read the latest information. I am not in the High risk category.COVID-19 NHS Link.
No one in my household is in the high risk category defined by the above link
I have not had a high temperature, persistent cough or had loss or change to your sense of smell or taste in the last 14 days
I will not attend if anyone in my household has had any of the symptoms identified by the NHS link above within the last 14 days.
I will wait in my car until collected by my Osteopath. To reduce contact with other patients.
I will bring my own Face mask (clinic can provide if needed).
I understand that on entry to the clinic I will wash my hands in soap and hot water for 20 seconds and dry on paper towels. I will use alcohol hand sanitiser on my way out.
I understand that Osteopathic Consultancy will be using anti-viral surfaces wipes to clean all surfaces that I come into contact with.
The appointment will be 1v1 with no one else in the clinic room. If the patient is under 18, one guardian is allowed in the clinic room
I understand that the Osteopath will be wearing PPE- Mask, Apron and Gloves.
Osteopathic Consultancy will replace the pillow case each time and I will not have a plinth cover.
I agree to these ongoing procedures for this and future appointments.
I agree to notify Osteopathic Consultancy if I or anyone in my household gets COVID 19.
I will avoid touching any surfaces when I am in the clinic.
I understand that my Osteopath and myself may be infected with Covid-19. We are both taking appropriate precautions to safeguard against the chances of transmission.
I consent to treatment from Osteopathic Consultancy and understand the risks of Coronavirus. I appreciate that all precautions are in place to minimise this risk.
By clicking ‘Submit’ I accept the above statements and I will agree and accept the procedures are in place for all our safety.
I am aware there is a 24 hour cancellation policy and I will liable for payment if I cancel within 24 hours
What were your fitness levels like when you were younger / in the past?
What are your fitness and activity levels like now?
What would you like to able able to do in the future in an ideal world?
1. Any changes in weight?
2. Any changes in appetite?
3. Any changes in your bowel function? Constipation/ Diarrhoea ? Colour?
4. Any Changes in Urination? Flow, Colour, Smell, Frequency?
5. Any Chest Pain, Palpitations, SOB, Cough?
6.Any SOB, Cough, Mucus Production?
7. Do you suffer from Asthma?
8. Do you smoke? - Number
9. Any changes in Special Senses?
10. Any Faints, Fits, Blackouts?
11. Any Headaches, Migraines?
12. Any change in Menstrual Cycle?- Heavy / light / None / Irregular, Spotting
13. Any Cyclic Back Pain?
14. Have you had any pregnancies?
15. Do you have any children?
16. Any Allergies?
17. Any Operations?
18. Any Accidents / Falls?
19. Are you on any Medication?
20. Have you had any Fractures?
21. Any Night Sweats?
22. Any Recent Travel?
23. Any Recent Immunisations?
24. Any Hospitalisations / Serious Illnesses?
25. Any Family or Genetic History of Illness?
26. You need an acupuncture certificate from us
27. If clinical necessary can we contact your GP? (We will ask you again at the time.)
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