COVID-19 Declaration Form
Please complete this form when you book an appointment with Pauline.
COVID-19 Declaration
Please complete this form for every appointment with Pauline
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Name*
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Date
Date Format: MM DD YYYY
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Address
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Phone*
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Email
Enter Email Confirm Email
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Have you or anyone in your household ever been diagnosed with Covid-19?*
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Yes
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No
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Have you or anyone in your household shown any of the following symptoms in the last 7 days? New dry cough, rash, diarrhoea, shortness of breath*
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Yes
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No
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If the answer to this question is yes, then the treatment can not continue until after 2 weeks of isolation with no symptoms in the household.
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Have you or anyone in your family been advised by the government as being clinically vulnerable and to shield?*
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Yes - me
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Yes - family member
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No
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Have you recently travelled abroad?*
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Yes - within the last 7 days
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Yes - over a week ago
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No
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Have you noticed any new rashes on your body or feet?*
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Yes
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No
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Have you experienced any pain or cramping in your legs/calves?*
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Yes
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No
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Do you promise to contact your therapist immediately if you or anyone in your household develops symptoms associated with covid-19 within 7 days of your treatment?*
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Yes
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If anything changes between now and your appointment time, do you promise to inform your therapist before your appointment date?*
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Yes
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Pauline will contact you the day before to see if anything has changed, and you will also be asked these questions when you arrive for your treatment.