In-Take Form


Pre-screening should be completed prior to patient attending the clinic or proceeding to receive treatment on arrival at clinic.

1. Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?

2. Have you been in close contact with a confirmed or suspected case of COVID-19 in the last 14 days? (i.e. les than 2meters for more than 15 mins accumulative in 1 day)

3. Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu-like symptoms now or in the past 14 days?

4. Have you been advised by a doctor or the HSE to self-isolate at this time?

5. Have you been advised by a doctor or the HSE to cocoon at this time?

6. Could you be classified as a person falling into the “at-risk” group around whom additional HSE guidelines apply? (e.g. underlying health conditions which place you at increased risk)

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