COVID 19 DECLARATION FORM

Body Logic Physiotherapy, Twickenham is committed to protecting the health of its patients and staff particularly with regard to Covid 19.

As part of the risk assessment for providing face to face physiotherapy we must ask you to provide assurances regarding your health. If you cannot provide these assurances then it will be best to opt for Virtual Physiotherapy sessions which are very effective in most cases.

1. Please read the government advice on Covid 19 symptoms and self isolation below:

If you live alone and you have symptoms of coronavirus illness (COVID-19), however mild, stay at home for 7 days from when your symptoms started after 7 days, if you do not have a high temperature, you do not need to continue to self-isolate. If you still have a high temperature, keep self-isolating until your temperature returns to normal. You do not need to self-isolate if you just have a cough after 7 days, as a cough can last for several weeks after the infection has gone.

If you live with others and you are the first in the household to have symptoms of coronavirus (COVID-19), then you must stay at home for 7 days, but all other household members who remain well must stay at home and not leave the house for 14 days. The 14-day period starts from the day when the first person in the house became ill.

For anyone else in the household who starts displaying symptoms, they need to stay at home for 7 days from when the symptoms appeared, regardless of what day they are on in the original 14 day isolation period.

2. I understand that I must inform Body Logic Physiotherapy if any of the following statements are applicable and need to be considered in the risk assessment as to whether face to face physiotherapy is more appropriate than virtual physiotherapy:

I am potentially at greater risk if I:

Am aged over 70
Am male
Am from a black, Asian and minority ethnic (BAME) group
Have a weakened immune system
Have a high BMI
3. I understand that it is particularly important to disclose any of the following in order to assess risk level:

Cancer, Diabetes, rheumatoid arthritis, infection, pregnancy, alcohol abuse, smoker/lung disease, long term steroid use.

4. I understand:

I should not make a face to face appointment if someone in my household is shielding.
I will need to attend the clinic on my own.
A face to face visit will likely lead to close physical contact with the physiotherapist.
I will be required to wear a face covering.
Body Logic will need to take my temperature using a non invasive head device and that Body Logic cannot continue with the session if my temperature is above 37.5 degrees celsius.
There are requirements for hand washing/sanitising on entering the building.
The clinic's requirements for appropriate social distancing where possible.
Despite all the precautions being taken by me and the clinic/therapist that there is a small chance of contracting Covid 19 which could have serious health consequences.