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COVID Patient Screening & Consent Form

Do you consider yourself to be in a high or moderate risk group?

https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk-from-coronavirus/

No                                   ___

Yes – Moderate Risk       ___

Yes – High Risk                ___

 

High risk (clinically extremely vulnerable)

  • 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 you 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
  • were born with a serious heart condition and are pregnant

Moderate risk (clinically vulnerable)

  • are 70 or older
  • are pregnant
  • have a lung condition that’s 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 disease, 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)

Do any of the following apply to you?        YES ¨           NO ¨

  • Have you been overseas in the last 14 days?
  • Have you been in close contact with or self isolating from a person with COVID-19 symptoms?
  • Have you been living in a household with someone who is self isolating due to covid 19 symptoms or has come into contact with someone with covid 19?

 

Have you got symptoms such as:

  • Fever (37.8c)
  • New and persistent cough
  • Shortness of breath or difficulty breathing
  • Chills
  • Muscle pain
  • Sore throat
  • New loss of taste or smell
  • Nausea
  • Vomiting
  • Diarrhoea

It is currently understood that Corona Virus spreads mainly through the respiratory tract in the form of droplets. Though most commonly spread through human-to-human contact, the virus has also been detected on surfaces for up to 72 hours after administration, particularly on plastic and stainless steel. Coronavirus has also shown an aerosol durability of at least three hours. Both factors increase transmission. An individual may become infected by touching an object that contains Coronavirus, then coming into contact with their respiratory tract (touching mouth, nose or eyes), or through the inhalation of Coronavirus particles in the air. Coronavirus is a global pandemic, as of 19.05.20 there have been over 25k deaths in the United Kingdom. The infection rate in Surrey, as of 19.05.20 is 0.2%.

Kingsmead Physiotherapy Clinic will use appropriate personal protective equipment and manage any clinical areas in accordance with COVID-19 infection prevention and control regulations

 

I understand that Kingsmead Physiotherapy Clinic clinicians will mitigate as far as reasonably practicable, through government social distancing guidance and shielding directives, the risk of transmitting the disease to patients and the wider general public. However it is impossible for us to remove that risk. During a face to face session it may not be possible/practical to maintain recommended social distancing.

 

I give my consent for Kingsmead Physiotherapy Clinic to complete an assessment and treatment sessions during the outbreak of Covid -19, 2020.

Signature……………………………………….            Print………………………………………………  Date……………………………………………

 

If filling in this form on behalf of a patient:

 

Name: ……………………………….. Relationship to patient: ……………………………….

Reason for filling in form on their behalf: ……………………………………………………

Kingsmead Physiotherapy Clinic, 224 Pollards Oak Road, Hurst Green, Oxted, Surrey  RH8 0JP

Tel & Fax: 01883 712987  mail@kingsmeadphysio.co.uk   www.kingsmeadphysio.co.uk

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