Norris Health Pre face-to-face appointment Podiatry screening

Patient Name		DOB
Screening Date

Please tick yes if you have any of the following

Symptom
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

Are you currently self-isolating for any reason?

As far as you know, in the last 14 days, have you or anyone in your household been in close,
unprotected contact with a confirmed or probable case of Coronavirus?

In the last 14 days, have you or anyone in your household travelled to or returned from a
country outside the United Kingdom?

Have you or anyone in your household been identified as high risk from Coronavirus (you
should have received a letter advising you of this)?

Have you or anyone in your household been identified as moderate risk from Coronavirus?
E.g. You're over 70, have Diabetes, Asthma, Heart Conditions, Are Pregnant etc

Please briefly explain the current problem that you wish to see a Podiatrist for:

Declaration:

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.

Your full name
Date
	I confirm that the above information is accurate

Consent to receive Podiatry 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

Your full name
Date
	I confirm that the above information is accurate

Can this patient be managed via remote consultation?	YesNo
Which CoP COVID-19 treatment category does this patient meet?	123None
Based on the information provided above is it appropriate to treat this patient in clinic or at home?	YesNo

Your full name
Date

Norris Health Pre face-to-face appointment Podiatry screening

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