Your Health Declaration

This electronic Health Declaration is strictly confidential in compliance with GDPR regs.

It is essential that you fill in all the fields below.

I undertake to keep the therapist updated on my health, should there be any changes to the answers given in next TEN DAYS.

I understand that COVID-19 is passed by close contact with others, is still present in Cardiff and that people without symptoms may be infectious.

I understand that City Marshall takes every precaution to ensure my health and safety, but risk of infection is still possible.

By submitting this form I here by consent to take part in and adhere to the Welsh Test Trace and Protect protocol.

YOUR FULL NAME
YOUR EMAIL
PHONE NUMBER
DATE OF BIRTH
IN THE LAST TEN DAYS ... 1/. I HAD A FEVER OVER 38c / 100F, which could mean you have felt unusually hot around your chest and back?	No Yes

2/. I HAD A NEW PERSISTANT COUGH OR SHORTNESS OF BREATH, meaning coughing a lot for more than an hour, or have had three or more coughing episodes in 24 hours - if you usually have a cough, is it worse than usual?	No Yes

3/. I had loss of or change to my usual smell or taste?	No Yes

4/. I had a new and unusually persistent headache, fatigue, sore throat or skin rash (see below)*	No Yes

5/. I HAD DIRECT PHYSICAL CONTACT WITH A KNOWN COVID-19 CARRIER, meaning for 15 minutes or longer and within two metres of a confirmed COVID-19 carrier.	No Yes

6/. That IN THE LAST SEVEN DAYS, I had direct contact with someone who has a fever higher than 38c or a persistent non allergic dry cough or loss of smell/taste? Meaning for 15 minutes or longer and within two metres of a SUSPECTED COVID-19 carrier.	No Yes

If you answered 'YES' to any of the six questions, please give details. BY SUBMITTING THIS FORM YOU THEREBY SIGN IT ANY OTHER COMMENTS? PLEASE USE BOX BELOW

*SEVEN CLASSIC COVID SYMPTOMS The ASK ZOE Symptom Tracker App has researched over 4m people. Having any of the additional four symptoms does not mean that you have COVID-19. However, you might want to consider getting tested. A NEW RASH, meaning a Hive-type skin rash on your feet or hands. This can be itchy or develop as a ‘prickly heat’ or chicken-pox type rash anywhere on the body. Sometimes known as COVID toes.

OUR ADDRESS :

QUAKER MEETING HOUSE
43 Charles Street
Cardiff, CF10 2GB

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YOUR HEALTH DECLARATION