Pre-Treatment Assessment

To ensure the safety of you, patients, our team and co-workers we would request that you complete this Pre-Treatment Assessment Form.

 

INSTRUCTIONS
We know that some of these questions can be difficult to accurately answer, so please don’t be concerned if you find it challenging, but simply answer to the best of your ability. We will then contact you and advise you whether we can provide face-to-face care or alternatively telephone advice or support. Thank you for your help and co-operation.






IMPORTANT PLEASE READ
You should NOT be attending the Clinic if you or someone in your household has been diagnosed with COVID-19 or has symptoms of it.

https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-households-with-possible-coronavirus-covid-19-infection

Have you or someone in your household has been diagnosed with COVID-19 or has symptoms of it? YesNo


IMPORTANT PLEASE READ
You should NOT be attending the Clinic if you are ‘extremely vulnerable’ and are therefore shielding.

https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

Are you in the 'extremely vulnerable' category? YesNo

YOUR SITUATION

Are you a key (critical) worker? YesNo

https://www.gov.uk/government/publications/coronavirus-covid-19-maintaining-educational-provision/guidance-for-schools-colleges-and-local-authorities-on-maintaining-educational-provision

Are you at low risk (no relevant health conditions which entitle you to an annual flu jab, and aged under 70)?
YesNo

https://digital.nhs.uk/coronavirus/shielded-patient-list


Are you caring for someone highly vulnerable who is shielding? YesNo

https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

CHIROPRACTIC CARE REQUIREMENTS

YOUR SYMPTOMS

Please grade your pain (or symptoms) where 1 is slight discomfort and 10 is severe pain:
12345678910


Are your symptoms worsening? YesNo


Are you taking medication of any kind for these symptoms? YesNo


Have you tried self-help measures (ie. exercise, medication) for this problem? YesNo


THE EFFECT OF YOUR CURRENT PROBLEM

Does your current problem affect your ability to do your job properly? YesNo


Do you anticipate that you will need NHS treatment (eg. contact your GP) for this problem? YesNo


If you or someone in your household has been diagnosed with, or has symptoms of, COVID-19, you should not attend the clinic at this time

https://www.nhs.uk/conditions/coronavirus-covid-19/check-if-you-have-coronavirus-symptoms/

If you are in the 'extremely vulnerable' category please make sure you have up to date advice from the government about how to keep yourself safe. We will do our best to keep appointments available at the beginning of each clinic sessions for patients in this group.

https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19