Norris Health Pre face-to-face appointment Physiotherapy screening

Please tick yes if you have any of the following

A fever (a temperature over 37.8 degrees centigrade) YesNo
New or worsening persistent cough YesNo
Shortness of breath YesNo
Loss of the sense of smell or taste YesNo
Difficulty breathing YesNo
Chills or body aches YesNo
Headaches or sore throat YesNo
Diarrhoea or vomiting YesNo


I solemnly and sincerely declare that the information I have provided is true and correct and
I make this solemn declaration conscientiously believing the same to be true. If any person
should suffer as a result of the information being found to be untrue or false, then I am
aware that I can be prosecuted for making a false declaration.

I confirm that the above information is accurate

Consent to receive Physiotherapy care at Norris Health

  • I have answered all questions relating to my exposure to Coronavirus (COVID-19) truthfully.
  • I understand that there is a potential risk of transmission of Coronavirus (COVID-19) as a
    result of attending the clinic and/or receiving treatment.
  • I have had the opportunity to ask all the questions I wish to, and all of my questions have
    been answered to my satisfaction.
  • I have read, agreed, and understood the statements above relating to Coronavirus
    (COVID-19) risk and consent to receive Podiatry care at Norris Health
I confirm that the above information is accurate

Has this patient had a remote physiotherapy consultation (triage)? YesNo