Covid-19 Pre Treatment Questionnaire

Please discuss with Emma any concerns, new or unusual symptoms in regards to feeling unwell. You can also use the NHS 111 online Coronavirus service for assistance.

Honesty is key so please respect the health of others and fill in this form with truthful representation of your current health.

Please scroll down to complete the questionnaire and for further information.

Thank you for your co-operation.

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COVID-19 Pre Treatment Questions

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Name: *

Date of Treatment *

Type of Treatment

E-mail address: *

Have you been vaccinated?

Please tick if applies and we may have to defer your treatment if you:

1) You have had a COVID-19 vaccine injection within the last 7 days

2) Have recently tested positive for COVID-19

3) Any symptoms of feeling unwell (especially cold symptoms, headache, runny nose, temperature, shortness of breath & taste/ smell changes)

5) Are waiting to have or for a COVID-19 test result

1) Do you currently have COVID-19 or any symptoms of COVID-19? *

2) Have you had COVID-19? *

3) Does anyone in your household or bubble have COVID-19 or symptoms of COVID-19? *

4) Have you been in close contact with anybody in the past 14 days who has symptoms of COVID-19? *

5) Are you classed as a vulnerable person for COVID-19?

Captcha (spam protection code): *

I herby agree that all information provided in this form is accurate at this present time. I understand this form is a mandatory requirement and if I do not fill in this form I could be refused treatment by the therapist. I confirm myself and no members of my household or 'bubble' have any symptoms of COVID-19 or that we have been self-isolating in the last 7 days. I understand that I use this service at my own risk in regards to COVID-19 and Emma Leeson Massage (ELM) Limited will not be held liable for any damages should I contract COVID-19 post-treatment. I agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

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