COVID19 Questionnaire

Please complete and submit this form to receive a pdf copy which you can print in preparation for your appointment.

Please do not sign it until you arrive for your session. Then you and your therapist will sign the form together.

Failure to bring this form to your appointment will result in your session being cancelled with full payment.

Client's Name*
First Last
Client's Email*
Questions
Please tick appropriate answer
1. Do you currently have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, or flu like symptoms?*
- Yes
- No
2. Over the past 14 days, have you had symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, or flu like symptoms?*
- Yes
- No
3. Have you been advised by a doctor to self-isolate at any time in the last 14 days?*
- Yes
- No
If Yes please explain*
4. Have you been advised by a doctor to cocoon during the time of COVID 19?*
- Yes
- No
If Yes – please give a brief outline of the reasons why (pre-existing condition / age)*
5. Have you been diagnosed with or suspected of having COVID-19 virus?*
- Yes
- No
If yes, was this in the last 14 days?*
- Yes
- No
6. Have you had any close contact with a person who was diagnosed with or a suspected case of COVID-19?*
- Yes
- No
If yes, was this in the last 14 days?*
- Yes
- No
7. Has anyone in your home or household been diagnosed with Covid-19 and advised to self-isolate or admitted to hospital in relation to Covid-19?*
- Yes
- No
8. Please review all the “Very High Risk” and “High Risk” groups listed in the HSE guidelines ( https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html ).*
- Yes
- No
9. Do you consider yourself to be in one of these groups?*
- Yes
- No
If Yes, please explain why*
- Yes
- No
Consent*
I have read and agree to following the guidelines and policies of Retuning ME Clinic (posted on their websites: www.kinesiology4u.ie and www.retuningme.com) and will not hold Retuning Me responsible for my lack of compliance to these procedures.
Consent*
I wish to declare that my answers to the above questions are correct and that to my knowledge I have not been in contact with any person who has a possible or confirmed diagnosis with Covid-19 in the last 14 days nor have I been symptomatic in the last 14 days.
Consent*
I consent to the above information being available for contact tracing and I agree to contact the clinic should I develop symptoms in the next 14 days.
I consider the treatment essential for my mental, physical, chemical and spiritual wellbeing.*
- Yes
- No
I have been recording my temperature for the last 14 days and it has been and is currently in the normal range (36.1 – 37)*
- Yes
- No
To submit this form, you need to accept our Privacy Statement*
- Accept
Privacy Statement

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Retuning Stress to Wellness With Nuala O’Connor
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