COVID 19 Screening Questionnaire

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To comply with current DHHS regulations, we need to ensure all sessions conducted are of an essential nature.

This Questionnaire is compulsory for all patients prior to each face to face appointment, to minimise risk of infection to both patients and practitioners.

Please read the following questions carefully and answer truthfully. Please be aware that this declaration is a legal document that can be audited by DHHS.

Upon submission, these answers will be reviewed by your practitioner, if there are any concerns they will be in contact.

ReachHealth is committed to ensuring the health and safety of our entire community. Thank you for your understanding in these challenging times.

Full name:

Email:

Best number to reach you:

What has lead to you seeking an Osteopathy or Acupuncture appointment today?

It was prescribed by my practitioner as part of my treatment plan

I'm in pain

I feel my health/condition may deteriorate without treatment

I'm struggling with day to day tasks

Other:

PLEASE CHECK UPDATED EXPOSURE SITES

https://www.coronavirus.vic.gov.au/exposure-sites#public-exposure-sites-in-victoria

Have you visited any of these sites during the dates/times listed, or within 1 hour of the listed time?

Yes

Clear selection

Are you awaiting COVID-19 test result?

Yes

Clear selection

Have you had close contact with someone confirmed to have COVID-19?

Yes

Clear selection

Do you currently have a fever?

Yes

Clear selection

Do you currently have a cough? (ANY cough, whether it be dry, productive, related to allergies or known pre-existing conditions)

Yes

Clear selection

Do you have a sore throat, loss of taste or smell, nausea, or any other signs of infection?

Yes

Clear selection

How much exposure have you had to large numbers of people in the last 14 days?

Lots of different people – High Risk

Small groups of people – Medium Risk

Very small numbers / strict social distancing / self-isolated – Low Risk

Clear selection

Are you happy to see your Osteopath / Acupuncturist, knowing that despite our best efforts at hygiene we cannot in a face-to-face consultation mitigate all risk? (Current hygiene policy here - https://reachhealth.com.au/covid-19-hygiene-procedures)

Yes

Clear selection

If you do get diagnosed with COVID-19 in the next 14 days, will you contact your treating practitioner as soon as feasibly possible?

Yes

Clear selection

This declaration is a legal document and may be audited by DHHS.

By completing and submitting this form you agree that this declaration is a legal document and may be audited by DHHS.

Yes, I agree - your answers will be saved.

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