Health Questionnaire, Declaration & Consent Form – COVID-19

Dietlind Gretschel Physiotherapy
PRACTICE NO: 072 000 0483885
BSc Physiotherapy (UP)
M (Phil) Human Rehabilitation Studies (US) Cum laude
Health Questionnaire, Declaration & Consent
Please complete the health declaration to the best of your knowledge and sign the consent form.
Questionnaire
Within the twenty-one (21) days immediately preceding the date of this health declaration, have you tested positive for the Coronavirus or been identified as a potential carrier of the COVID-19 virus?
- Yes
- No
If your answer is YES, please elaborate:
Please indicate if you are currently experiencing or have experienced any of the following symptoms, commonly associated with the Coronavirus:
- Fever (≥ 37.4˚)
- Cough
- Runny nose
- Cold sweats
- Shortness of breath
- Sore throat
- Myalgia/body pains
- Fast breathing
- Loss of taste/small
Within the twenty-one (21) days immediately preceding the date of this health declaration, have you been in direct contact with or the immediate vicinity of any person now known to be carrying the Coronavirus or any person identified as a potential carrier of the Coronavirus?
- Yes
- No
If your answer is YES, please elaborate:
If your answer is YES, please elaborate:
Within the twenty-one (21) days immediately preceding the date of this health declaration, have you been in any location found to be hazardous and/or potentially infected with the Coronavirus, such as countries deemed high risk for Coronavirus and/or a health care facility where patients with SARS-CoV-2 infections are being treated?
- Yes
- No
If your answer is YES, please elaborate:
I declare that I have read and understood this questionnaire and that all information was submitted truthfully.*
- Yes
Declaration
I can account for all locations visited over the past twenty-one (21) days and shall provide an exhaustive list of all locations visited and modes of transportation used on request by the physiotherapist.

I agree to immediately notify the physiotherapist:
- Of any changes in my health status up to thirty (30) days following this appointment
- If I test positive for the Coronavirus up to thirty (30) days following this appointment
- If I need to go into quarantine due to being exposed to a person who has tested positive for the Coronavirus
I will always wear a mask and will take all reasonable precautions recommended by the physiotherapist while receiving treatment.

I consent to having my temperature taken by any representative of the practice prior, during, and/or after any treatment.

I agree to provide any follow up information reasonably requested by the physiotherapist related to the COVID-19 pandemic.

I acknowledge and accept that this declaration shall be governed by the laws of South Africa. I irrevocably agree that the courts of South Africa shall have jurisdiction to hear and determine any suit, action or proceeding, and to settle any dispute which may arise out of, under, or in connection with this declaration and for such purposes hereby irrevocably submit to the jurisdiction of such courts. Nothing contained herein shall limit the right of Dietlind Gretschel Physiotherapy to take proceedings in any court.
I declare that I have read and understood this declaration and that I agree to its provisions.*
- Yes
Consent for physiotherapy treatment
I (full name and surname)*
ID number*
Email address
Cellphone number
understand and agree that, should the practitioner believe that I/my child may have been exposed to COVID-19 and/or do have COVID-19, she will refer me/my child for tests and, I understand, that the results of such tests must be reported, by law, to the National Institute of Communicable Diseases (NICD).

I understand that, even though this physiotherapy practice is taking all the necessary precautions to mitigate all possible risk, I/my child am/are at risk of contracting or transmitting the COVID-19 virus by visiting this facility or attending a treatment session at the practice. I, therefore, freely and voluntarily consent to this service, and I understand the risks thereof.
Signed at (place)*
on (date)*
Date Format: DD slash MM slash YYYY
Patient/parent signature*
(which the practice and patient agree can be electronically affixed)
Please add me to your mailing/contact list
- Yes
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Dietlind Gretschel Physiotherapy

Health Questionnaire, Declaration & Consent

Questionnaire

Declaration

Consent for physiotherapy treatment

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