COVID-19 Patient Screening

Under government guidance we must screen patients before treatment so please answer the following questions. Please read our Patient Guide to COVID-19 before you complete this form.

Have you responded already to this questionnaire and are your medical details the same as they were when you first responded?
Your Symptoms
Do you feel your symptoms would get worse without treatment?
Do your symptoms/pain affect your normal daily activities?
Any COVID-19 symptoms
In the past 14 days have you developed any of the following symptoms – cough / fever / loss of smell?
In the past 14 days have you been in contact with anyone with these symptoms or anyone with confirmed COVID-19?
Your medical background / risk group
Have you or anyone in your household received a government letter advising you to shield or do you feel you are high risk?
Do any of the following apply to you?
  • Aged 70 or over
  • Take medication that can lower immunity e.g low dose steroids 
  • Pregnant
  • Obese or BMI 40 or above
  • Lung condition e.g asthma, COPD, emphysema or bronchitis
  • Heart disease e.g heart failure
  • Diabetes
  • Chronic kidney disease
  • Liver disease e.g hepatitis
  • A condition affecting the brain or nerves e.g Parkinson’s, multiple sclerosis, cerebral palsy, motor neurone disease
  • A condition that means you have high risk of getting infections
Have you travelled internationally in the last 14 days?

Thank you for your responses, you’ll be redirected to our online booking system. If you’re not redirected it’s because government guidance suggests we talk to you first, please bear with us!

If you have any questions, please ring or email Rebecca Butterfield at Emsworth Osteopaths.

Tel 07779 769638

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