Spinalphysio Covid-19 Risk Assessment Title ---Mr.Mrs.Miss.Ms.Dr First Name Last Name Date of Birth Address Gender MaleFemaleMx Post Code Telephone (Mobile) Telephone (Work) Telephone (Home) Email I give consent to have appointment reminders and treatment specific information by post, text or email. General Have you tested positive to COVID-19 in the past 7 days? YesNo Are you waiting for a COVID-19 test or the result? YesNo Have you or anyone in your household been suffering with a: High temperature? YesNo New or continuous cough? YesNo Loss or change to your sense of smell or taste? YesNo Has anyone in your household tested positive to COVID-19 or has symptoms in the last 14 days? YesNo 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? YesNo Moderate Risk Are you over the age of 70? YesNo Are you from a Black, Asian and Minority Ethnic (BAME) communities? YesNo Are you pregnant? YesNo Do you have a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis)? YesNo Do you have heart disease (such as heart failure)? YesNo Do you have diabetes? YesNo Do you have chronic kidney disease? YesNo Do you have liver disease? YesNo Do you have a condition affecting the brain or nerves? YesNo Do you have a condition that means you have a high risk of getting infections? YesNo Are you taking any medicine that can affect your immune system (such as low doses of steroids)? YesNo Are you very obese (a BMI of40 or over)? YesNo High Risk Have you had an organ transplant? YesNo Are you having chemotherapy or antibody treatment for cancer, including immunotherapy? YesNo Are you having an intense course of radiotherapy for lung cancer? YesNo Are you having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)? YesNo Do you have blood or bone marrow cancer? YesNo Have you had a stem cell or bone marrow transplant in the last six months or are you taking immunosuppressant medicine? YesNo Do you have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)? YesNo Have you a condition that means you have a very high risk of getting infections (such as SCID or sicklecell)? YesNo Are you taking any medicines that make you more likely to infection (such as high dose steroids or immunosuppressants)? YesNo Have you got a serious heart condition? YesNo Δ
