FORM

REQUIRED FORM-Health & Safety

PRE-TREATMENT-SCREENING CHECK (COVID-19)  Pre-screening is now a public health recommendation for patients prior to attending for treatment. This measure is an effort to minimise the risk of the spread of COVID-19 within our communities. Pre-screening should be completed prior to a patient attending the clinic as a risk management protocol.

 

Name  

 

Date  

 

Contact Number  

 

PRE-TREATMENT-SCREENING QUESTIONS: circle Yes or No

 

YES NO
Have you been diagnosed with confirmed or suspected  COVID-19 infection in the last 14 days?
YES
NO
Have you been in close contact with a confirmed or suspected case of COVID-19 in the last 14 days?  (i.e. less than 2m for more than 15mins accumulative in 1 day).
YES
NO
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?
YES
NO
Have you been advised by a Doctor or the HSE to self-isolate at this time?

 

YES
NO
Have you been advised by a Doctor or the HSE to cocoon at this time?

 

YES
NO
Could you be classified as a person falling into the “at risk” group around whom additional HSE guidelines apply? (e.g. underlying health conditions which place you at increased risk)
YES
NO

 

 

I understand that this information is required for the purposes of public health & will be kept on file for a 2 month period from the date of signing. I confirm that the above information is true & accurate from the date of signing. I understand that my personal information including my name & contact details may be shared with the Health Service Executive(HSE) for the sole purpose of contact tracing in line with public health guidelines only if requested.

 

Signature ____________________________________     Date: ___/___/_____