Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently experiencing any symptoms associated with Covid-19? *

Yes

No

Are you experiencing any of the following: *

(please tick if applicable)

Persistent dry cough

Headache

Fever

Joint or muscle pain

Loss of smell/taste

Sore throat

Difficulty breathing

Runny nose

Chest pain

None of the above

Is anyone in your household experiencing symptoms associated with Covid-19? *

If YES you will need to self isolate for 14 days.

Yes

No

Have you been in contact with anyone experiencing Covid symptoms in the last 7 days? *

If YES, you will need to get tested via the NHS.

Yes

No

Have you returned from Travelling abroad in the last 14 days? *

Yes

No

Have you previously been tested for Covid-19? *

Yes

No

Have You Been Vaccinated? *

1st Vaccine Only

Both Vaccines

Not Vaccinated

Prefer not to say

Declaration: I herewith confirm that I will notify my therapist in case I develop Covid-19 symptoms and I authorise the therapist to use my details for track and trace and to notify me or 
anyone I have been in contact with in case of Covid-19 symptoms. *

Tick box to confirm authorisation

I confirm