Quesionnaire | CAM Aromatherapy

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Date of Treatment

My body temperature is lower than 98.6°F/ 37.5°C (Please defer your treatment if your body temperature is higher than usual.)

I am not experiencing the symptoms: fever, cough, sore throat (Please defer your treatment if you: are waiting for a COVID-19 test result; have recently tested positive for COVID-19; or have a high temperature, new continuous cough, or a loss or change to your sense of smell or taste. If you currently have symptoms of COVID-19 but have not yet had a test, please arrange one as soon as possible. If you have any other new or unusual symptoms, please discuss these with me before your appointment.)

I haven’t been in close contact with a Covid-19 patient in the last 14 days (Have you been in close contact with anyone else in the past 10 days who has symptoms of COVID-19 or been contacted by the NHS Test and Trace service and told to self-isolate? If yes to either please defer your appointment.)

Note:

* If you have had COVID-19 before and received medical treatment, you must seek verbal or written consent from your GP or consultant before treatment.

* If you are currently shielding please defer your treatment until you are no longer required to shield.

* If you are clinically extremely vulnerable please seek written consent from your GP, midwife or consultant and discuss this with me before treatment.

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!