Good Health TCM L'boro Clinic Health Screening form

1. Good Health TCM Health screening pre-attendance form


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Pre-attendance HEALTH SCREENING QUESTIONS

Although, identifying people as clinically extremely vulnerable (CEV) is no longer legally necessary.
As a healthcare setting where a many of our patients are people whose immune system put them more at risk of serious illness from respiratory infections [including Respiratory syncytial virus (RSV), Flu or COVID-19 - despite vaccination.]
At our clinic, we follow UKHA and WHO Infection prevention and control (IPC) guidance which are set in place on our risk assessment policy to protect everyone.
 
Please find below our health screening questionnaire. This needs to be completed and sent back to us a day before your treatment day.
Without this record filled in, your appointment cannot go ahead.

Please, insert your details, the information required and answer YES or NO to the questions.

Also read the attachment attached to your booking named "Day of the Treatment" sent to your email.
This explains what you should do, and what to bring with you, INCLUDING 1 or 2 towels and details about the need of wearing a FACE COVER/MASK at the clinic, according to UKHA IPC guidance for healthcare settings.

IF YOU ARE FEEL RECENTLY UNWELL (FEVER or FLU-like FEEL), CONTACT US ON 01509 236 777 TO CHECK IF WE NEED TO CANCEL YOUR APPOINTMENT  

Find more about Safe Healthcare Practices and IPC info:
PATIENT NOTICE (regarding our Infection prevention and control (IPC) risk assessment policy) :
Our clinic, according to this same guidance publication, has chosen currently will to continue to follow healthcare settings guidance issued by UKHA and WHO Infection prevention and control (IPC) which are set in place on our risk assessment policy to protect everyone in our risk assessment.
As our risk policy was reviewed in the beginning of February 2023 and due to high potential risk to many of our high-risk patients and staff, which consequences could bring severe damage our SME healthcare business, we chosen to continue to continue IPC in our risk assessments.
This information can be checked as well in the UK Gov Guidance regarding "Reducing the spread of respiratory infections, including COVID-19, in the workplace."
 

1. Please provide the date you will be attending your treatment: *

   DD/MM/YYYY 
 
 

2. Please insert below your contact details : *

*
*
*
 

3. Do you currently have ANY of the below symptoms such as respiratory issues, a virus or COVID-19?

> a high temperature (over 38 °C but you do not need to measure your temperature);
> a new continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours;
> loss/change of sense of smell/taste;
> an unusual feeling of fatigue;
> an unusual shortness of breath;
> an unusual feeling of aching body;
> an unusual headache;
> a sudden sore throat;
> blocked or runny nose (not from an existing condition like sinusitis, rhinitis or hay fever);
> an unusual loss of appetite;
> an unusual diarrhoea (not from an existing diagnosed condition);
> an unusual feeling sick or being sick (not from an existing diagnosed condition). *

 

4. Does anyone in your household have ANY of the symptoms listed above or have COVID-19? *

 

5. Have you had the Flu / Covid-19 Vaccine?
*

NoYes, bothYes, FluYes, both and Covid 2nd dose & booster(or 3rd dose)
 

6. Have you been in close contact with anyone recently with symptoms of a respiratory virus ( such as the RSV) Flu or COVID-19? 
(for example this could be situations like visiting someone at the hospital or nursing home) *

 

7. Are you classed of being of risk of serious illness from respiratory tract  such as the Respiratory syncytial virus (RSV) or COVID-19**?
** These conditions could be listed below or others told by a healthcare professional, including severe immunosuppression, which includes people who have or may recently have had:
  • a blood cancer (such as leukaemia or lymphoma)
  • a weakened immune system due to a treatment (such as steroid medicine, biological therapy (sometimes called immunotherapy), chemotherapy or radiotherapy
  • an organ or bone marrow transplant
  • a condition that means you have a very high risk of getting infections
  • a condition or treatment your specialist advises makes you eligible for a third dose
  • Down’s syndrome
  • certain types of cancer or have received treatment for certain types of cancer
  • sickle cell disease
  • certain conditions affecting their blood
  • chronic kidney disease (CKD) stage 4 or 5
  • severe liver disease
  • an organ transplant
  • certain autoimmune or inflammatory conditions (such as rheumatoid arthritis or inflammatory bowel disease)
  • HIV or AIDS who have a weakened immune system
  • inherited or acquired conditions affecting their immune system
  • rare neurological conditions: multiple sclerosis, motor neurone disease, Huntington’s disease or myasthenia gravis
Identifying people as clinically extremely vulnerable (CEV) is no longer necessary. However, a smaller number of people whose immune system put them more at risk of serious illness from respiratory infections like Respiratory syncytial virus (RSV) or COVID-19**, despite vaccination.
*

 

8. Are you able to wear a face cover when attending your treatment?
(either a brand new surgical mask, provided at arrival or by bringing your own - if allergic to standard clinic masks like our clinic's paper masks)
As healthcare setting, we must ensure that everyone, including our high risk and most vulnerable patients are safe to be treated at our clinic. Therefore we keep these strongly recommended guidelines from UK Health Security Agency to to reduce any sort of respiratory infections, not only SARS-CoV2 (Covid-19) but the common Flu or the Respiratory Syncytial Virus (RSV). *

 

9. I agree that my contact can be used for NHS medical or emergency services, if required? *

 

10. I agree to my contacts/email address being kept until further notice or issues concerning my treatment?
(you can ask us to remove you at any time) *

 

11. I confirm I have read the attached document "Day of the Treatment" and understand these terms and changes made to our clinic practices
(if not, or in case of any doubt, please quit and close this survey and contact our clinic line 01509236777 or email us at lboroclinic@goodhealthtcm.co.uk for more information) *

I agree
Yes