Health Declaration Form

Health Declaration Form – COVID-19

*** Required to be completed by every patient prior to commencement of outpatient Physiotherapy treatment at SHAMIM KHAN PHYSIOTHERAPIST

Patient Health Declaration Form

I, (insert full name below) hereby certify, represent, and warrant as follows: Within the twenty-one (21) days immediately preceding the Date of this Health Declaration Form (“Declaration”): *

SECTION A: Please read the following statements and then answer either YES or NO below. If NO provide details in the block below the section:

a. I HAVE NOT : tested positive or preemptively positive with the Coronavirus or been identified as a potential carrier of the COVID-19 virus or similar communicable illness (“Coronavirus”) ? *

Select Yes or No

b. I HAVE NOT: experienced any symptoms commonly associated with the Coronavirus i.e.: fever (≥38⁰C), cough, sore throat etc. ? *

Select Yes or No

c. I HAVE NOT been in any location positively designated as hazardous and/or potentially infected with the Coronavirus by a recognized health or regulatory authority, such as countries deemed high risk for Coronavirus as per the President’s declaration in terms of the National Disaster ? *

Select Yes or No

d.I HAVE NOT: been in direct contact with or the immediate vicinity of any person I knew and/or now know to be carrying the Coronavirus or has been identified as a potential carrier of the Coronavirus? *

Select Yes or No

If you answered NO to any of the questions in SECTION A please give details in the block below:

SECTION B. Read the following statements and select YES OR NO from the drop-down box. If you answered NO provide reasons in the text area below this section..

I CAN account for all locations visited over the previous twenty-one (21) days and shall provide an exhaustive list of all locations visited and modes of transportation used on request. * *

SELECT YES OR NO

I AGREE to notify the Physiotherapist of any change in status, including diagnosis with Coronavirus and/or quarantine, within thirty (30) days either before or following this appointment. * *

SELECT YES OR NO

I WILL, if asked, wear a mask at all times while receiving treatment and will take all reasonable prophylactic steps that may be recommended by the Physiotherapist. * *

SELECT YES OR NO

I WILL consent to having my temperature taken by any representative of the practice prior, during, and/or after any treatment, and will provide any follow up information reasonably requested by the Physiotherapist * *

SELECT YES OR NO

If you answered NO to any of the statements in SECTION B, please provide your reasons in the block below:

Due to the nature of the CORONA virus I ACKNOWLEDGE and ACCEPT the potential risk of exposure to the virus during my visit at this facility, even with all possible risk has been mitigated by the practice and all precautions as described by law has been put in place. * *