Spinalphysio Covid-19 Risk Assessment

Title

First Name

Last Name

Date of Birth

Address

Gender

Post Code

Telephone (Mobile)

Telephone (Work)

Telephone (Home)

Email

Have you tested positive to COVID-19 in the past 7 days?

Are you waiting for a COVID-19 test or the result?

Have you or anyone in your household been suffering with a:

High temperature?

New or continuous cough?

Loss or change to your sense of smell or taste?

Has anyone in your household tested positive to COVID-19 or has symptoms in the last 14 days?

Have you been notified by NHS Track & Trace that in the last 14 days you or anyone living with you has been in contact with a person testing positive to COVID-19?

Are you over the age of 70?

Are you from a Black, Asian and Minority Ethnic (BAME) communities?

Are you pregnant?

Do you have a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis)?

Do you have heart disease (such as heart failure)?

Do you have diabetes?

Do you have chronic kidney disease?

Do you have liver disease?

Do you have a condition affecting the brain or nerves?

Do you have a condition that means you have a high risk of getting infections?

Are you taking any medicine that can affect your immune system (such as low doses of steroids)?

Are you very obese (a BMI of40 or over)?

Have you had an organ transplant?

Are you having chemotherapy or antibody treatment for cancer, including immunotherapy?

Are you having an intense course of radiotherapy for lung cancer?

Are you having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)?

Do you have blood or bone marrow cancer?

Have you had a stem cell or bone marrow transplant in the last six months or are you taking immunosuppressant medicine?

Do you have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)?

Have you a condition that means you have a very high risk of getting infections (such as SCID or sicklecell)?

Are you taking any medicines that make you more likely to infection (such as high dose steroids or immunosuppressants)?

Have you got a serious heart condition?