Covid-19 Screening & Consent Form

1) Have you had a fever in the last 7 Days (feeling hot to touch on your chest and back)

 

Yes

No

 

2) Do you now, or have you recently had a 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)

 

Yes

No

 

3) Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms?

 

Yes

No

 

4) Have you been told to stay at home, self-isolate or self-quarantine?

 

Yes

No

 

5) Do you have any other symptoms that may mean you have a Covid-19 infection? (loss of taste and smell, unusual fatigue or shortness of breath)

 

Yes

No

 

6)Have you travelled abroad in last 7 days?

 

Yes

No

 

7) High risk (clinically extremely vulnerable).

Please select YES if ANY of the following apply to you

  • had an organ transplant

  • currently having chemotherapy or antibody treatment for cancer, including immunotherapy

  • currently undergoing an intense course of radiotherapy (radical radiotherapy) for lung cancer

  • having targeted cancer treatment that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors

  • have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)

  • had a bone marrow or stem cell transplant in the past 6 months, or still taking immunosuppressant medicine

  • told by a doctor that you have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)

  • have a condition that means you have a very high risk of getting infections (such as SCID or sickie cell)

  • taking medication that makes you much more likely to get infections (such as high doses of steroids)

  • pregnant and have a serious heart condition

 

Yes

No

 

If you answer YES to any of the above, you are classified as clinically extremely vulnerable and the government advise you exercise “shielding”. Current government advice states you should stay at home at all times and avoid any face to face contact with anyone apart from your own household.

 

8)People at moderate risk (clinically vulnerable)
or older

  • pregnant

  • have a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis)

  • have a heart disease (such as heart failure)

  • have diabetes

  • have a chronic kidney disease

  • have a liver disease (such as hepatitis)

  • have a condition affecting the brain or nerves (such as Parkinson disease, Cerebral palsy, multiple sclerosis, motor neuron disease)

  • have a condition that means you have a high risk of getting infections

  • taking medicine that can affect the immune system (such as low doses of steroids)

  • very obese (BMI of 40 and above)

 

Yes

No

 

If you selected YES you’re at moderate risk from coronavirus and it is very important you follow the advice of social distancing.

 

9) I am seeking pain relief treatment and do not find pain medication adequate alternative

 

Yes

No

 

Having read this form,you hereby confirm all answers are true to the best of my knowledge and understand because outdoor training sessions may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission including Covid-19.