Patient Health Questionnaire

Have you been tested for COVID 19 in the past two weeks?*

What was to outcome?*

Please check the box to confirm the statements below

I have not been diagnosed with or cared for someone with COVlD in the past two weeks
I have not shown symptoms of COVID 19 or come in close contact with anyone exhibiting these symptoms in the past two weeks
I have not travelled outside my immediate area for the past two weeks
I do not have a cough, fever, chills, shortness of breath or loss of taste or smell
lf I begin to show symptoms of COVID 19 within the next two weeks, I will contact my Physiotherapist
I will follow all Government & HSE rules posted in the practice to keep,mvself, my practitioner and those around me safe

Name*

Contact Number*

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