Date: Click or tap to enter a date. Enter Patient Name and No. Click or tap here to enter text.
Do you, or anyone living in your house, or had contract with have Corona Virus or got the following symptoms?
• High temperature – 37.8 this means you feel hot to touch on your chest or back (you do not need to use a thermometer)…………… .Choose an item.
• New, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)…………………………………………………………………………………Choose an item.
• Loss or change to your sense of smell or taste – this means you’ve noticed you cannot smell or taste anything, or …….……………...Choose an item.
• Things smell or taste different to normal…………………………………………………………………………………………………Choose an item.
People at high risk from coronavirus include people who: (Extremely vulnerable) Answer Yes =Y No= N Put Capital lock on
• have had an organ transplant………………………………………………………………………………………………….…Choose an item.
• are having chemotherapy or antibody treatment for cancer, including immunotherapy………………………………………..Choose an item.
• are having an intense course of radiotherapy (radical radiotherapy) for lung cancer………………………………………...…Choose an item.
• having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors…Choose an item.
• have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)………………………………………………Choose an item.
• have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine… ...…Choose an item.
• have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)………Choose an item.
• have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell)……………………Choose an item.
• taking medicine that makes them much more likely to get infections(such as high doses of steroids / immunosuppressant)…..Choose an item.
• have a serious heart condition and are pregnant…………………………………………………………………………………Choose an item.
People at moderate risk clinically vulnerable from coronavirus include people who:
• are 70 or older……………………………………………………………………………………………………………………Choose an item.
• are pregnant………………………………………………………………………………………………………… …………Choose an item.
• have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)………………………… ……….Choose an item.
• have heart disease (such as heart failure) ………………………………………………………………………………… ……Choose an item.
• have diabetes…………………………………………………………………………………………………………………….Choose an item.
• have chronic kidney disease……………………………………………………………………………………………………..Choose an item.
• have liver disease (such as hepatitis)…………………………………………………………………………………………….Choose an item.
• have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)………………………………………………………………………………………………………Choose an item..
• have a condition that means they have a high risk of getting infections………………………………………………...………Choose an item.
• are taking medicine that can affect the immune system (such as low doses of steroids)………………………………………..Choose an item.
• are very obese (a BMI of 40 or above)…………………………………………………………………………………………..Choose an item.
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Osteopath: Click or tap here to enter text.