COVID-19 Risk Assessment & Screening

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COVID-19 Risk Assessment

    COVID-19 Risk Assessment

    What is your COVID-19 vaccination status?


    Not Vaccinated


    Single Vaccinated


    Double Vaccinated


    Double Vaccinated and Booster

    Do you have any of the following?

    Yes

    No

    Chronic respiratory disease e.g., COPD, Asthma, etc.


    Y


    N

    Currently receiving active cancer treatment or within the last 12 months


    Y


    N

    Severe immunodeficiency or taking strong immunosuppression medication


    Y


    N

    Received an organ transplant


    Y


    N

    Cardiovascular disease e.g., stroke, heart attack, angina, etc.


    Y


    N

    Chronic kidney or liver disease


    Y


    N

    Diabetes


    Y


    N

    Neurological conditions e.g., Parkinson’s Disease, Multiple Sclerosis, etc.


    Y


    N

    Spleen problems


    Y


    N

    Pregnant with known heart disease


    Y


    N

    Obese (BMI > 40)


    Y


    N

    High Risk

    Based on your answers, you have a high risk of transmitting and becoming seriously unwell from COVID-19.

    Provide Physiotherapy Service advise a video or telephone consultation for your physiotherapy assessment although if you still would prefer to attend a face-to-face appointment despite these risks, complete the COVID-19 Screening Tool and follow the instructions sent via SMS/Email.

    If you have any further questions, please contact the Care Co-ordination Centre on 0300 1310 111 or by email at provide.askus@nhs.net.

    Medium Risk

    Based on your answers, you have a medium risk of transmitting or becoming seriously unwell from COVID-19.

    Provide Physiotherapy Service advise a video or telephone consultation for your physiotherapy assessment although if you still would prefer to attend a face-to-face appointment despite these risks, complete the COVID-19 Screening Tool and follow the instructions sent via SMS/Email.

    If you have any further questions, please contact the Care Co-ordination Centre on 0300 1310 111 or by email at provide.askus@nhs.net.

    Low Risk

    Based on your answers, you have a relatively low risk of becoming seriously unwell from COVID-19.

    If you would prefer to attend a face-to-face appointment rather than video consultation for your physiotherapy assessment, complete the COVID-19 Screening Tool and follow the instructions sent via SMS/Email.

    If you have any further questions, please contact the Care Co-ordination Centre on 0300 1310 111 or by email at provide.askus@nhs.net.

    Please select all options.

    COVID-19 Screening Tool

      COVID-19 Screening Tool

      Yes

      No

      1. Do you have a high temperature, new continuous cough and/or loss of taste or smell? (If yes – Click Here for NHS advice)


      Y


      N

      2. Do you or any member of your household/family have a confirmed diagnosis of COVID-19 in the last 10 days?


      Y


      N

      3. Are you or any member of your household/family waiting for a COVID-19/SARS-CoV-2 PCR test result?


      Y


      N

      4. Have you travelled internationally in the last 10 days to a country that is on the government red list? Click Here for the current red list of countries and territories


      Y


      N

      5. Have you or any member of your household/family been advised to isolate by any NHS organisation in the last 10 days?


      Y


      N

      Based on your answers and according to government guidance regarding measures to reduce COVID-19 transmission, you are currently unable to attend a face-to-face appointment.

      Please request a video or telephone consultation for your physiotherapy assessment following the instructions sent via SMS/Email.

      If you have any further questions, please contact the Care Co-ordination Centre on 0300 1310 111 or by email at provide.askus@nhs.net.

      Based on your answers, you have the option to attend a face-to-face appointment.

      Please request a face-to-face, video or telephone appointment, depending on your preference, for your physiotherapy assessment following the instructions sent via SMS/Email.

      If you have any further questions, please contact the Care Co-ordination Centre on 0300 1310 111 or by email at provide.askus@nhs.net.

      Please select all options.

      Please select all options.