Covid Declaration

HomeCovid Declaration
Patient Screening Questionnaire for COVID – 19. Please complete this form within 48 hours before you attend your massage appointment, and sign the declaration at the end.

    Have you had a Covid Vaccination? If so which one?

    1st Vaccination 2nd Vaccination
    Name of vaccine?
    Date of vaccination?
    Vaccine number?

    Do you have any of the following symptoms

    Question No Yes Detail
    New persistant cough No Yes
    New shortness of breath or difficulty breathing No Yes
    Raised temperature/fever (over 37.8'C) No Yes
    New headaches No Yes
    New fatigue or tiredness No Yes
    Loss or change of smell/taste No Yes
    Nausea, vomiting or diarrhoea No Yes
    New rash anywhere on your body No Yes
    Is anyone in your household suffering from these symptoms? No Yes
    Have you been tested or due to be tested for Covid-19? No Yes
    Have you been in close contact with anyone exhibiting symptoms of COVID-19? No Yes
    Have you travelled anywhere abroad in the last 14 days?? No Yes
    If yes, where, and when did you return?? No Yes
    Did you receive any notification asking you to self-isolate? No Yes

    Have you been classified as belonging to any of the following vulnerable categories?

    Question No Yes Detail
    Have you had an organ transplant? No Yes
    Are you undergoing cancer treatment? No Yes
    Have you had a bone marrow or stem cell transplant within the last 6 months? No Yes
    Do you have a severe respiratory condition? No Yes
    Is your immune system compromised in any other way? No Yes
    Do you have a disease of the heart, liver or kidney? No Yes
    Are you diabetic? No Yes
    Do you have a neurological disease? No Yes
    Do you have a condition, or medication, that makes you at high risk of developing infections? No Yes
    Do you have a very high BMI (kg/m2 of over 40)? No Yes

    IF YES TO ANY - We will be in touch with you to discuss your treatment options

    Question No Yes Detail
    Does your complaint affect your ability to work (or would it if you were working) No Yes
    Does your pain ever exceed 6/10? No Yes

    Checks on the door

    Lateral flow test Positive Negative




    *Required
    • I acknowledge the contagious nature of the Coronavirus/Covid-19 and that the WHO and many other Public Health authorities still recommend practicing social distancing.
    • I further acknowledge that Firm and Tender Hands has put in place preventative measures to reduce the spread of the Coronavirus/Covid-19.
    • I further acknowledge that Firm and Tender Hands cannot guarantee that I will not become infected with the Coronavirus/Covid-19.
    • I understand that the risk of becoming exposed to and/or infected by the Coronavirus/Covid-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, clinic staff, and other clinic patients and their families.
    • I voluntarily seek services provided by Firm and Tender Hands and acknowledge that I am increasing my risk to exposure to the Coronavirus/Covid-19.
    • I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

    In consideration of my participation in the foregoing, the undersigned acknowledge and attest that:
    • I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
    • I have not travelled internationally within the last 14 days.
    • I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/Covid-19.
    • I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by local public health authorities.
    • I am following all WHO recommended guidelines as much as possible and limiting my exposure to the Coronavirus/Covid-19.
    • I will bring my own towels to keep warm during the massage in order to reduce risk of COVID-19 transmission.
    • I will submit to a temperature check at the door of the therapy room on arrival.
    • I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscientiously believing the same to be true, further to this if any of the answers to these above questions change between the time of filling in this form, and the time of my appointment, I will inform the practitioner. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.