Coronavirus (COVID-19)
Symptom Tracker

Patient Name

Patient Date of Birth

Patient Email

Patient Contact Number

Patient Address

Are you currently diagnosed with or believe you may have COVID-19?

Yes No

Are you currently self-isolating?

Yes No

Have you had any of these symptoms of COVID-19 in the past 14 days?

High temperature or fever (above 37.8ºC)?

Yes No

New or worsening continuous cough?

Yes No

New loss of taste or smell?

Yes No

New unexplained shortness of breath?

Yes No

New or worsening chills, body aches or headaches?

Yes No

Gastrointestinal upset (diarrhoea and/or vomiting)?

Yes No

Have you been in contact with a COVID-19 confirmed or suspect case in the previous 14 days?

Yes No

Have you travelled to, or returned from, a country outside of the United Kingdom?

Yes No

Have you, or those in your household, been identified as high risk from coronavirus (clinically extremely vulnerable)?

Yes No

If you answer YES to any of these questions, you should stay at home, contact your GP and/or complete the NHSX Track and Trace form, and follow the clinical guidance issued to you. Inform Physio may contact you in due course to discuss your responses further. Please be aware that we may be required to provide your contact details to the NHS Track and Trace System if, after your treatment, your therapist displays symptoms of COVID 19 or if Inform Physio are notified by the NHS Track and Trace System of having been in contact with an individual who has displayed COVID 19 symptoms.

By clicking 'Send', you automatically agree to the storing and processing of your data in line with our GDPR-compliant Privacy Policy which can be viewed at inform.physio/privacy-policy.

Inform Physio Ltd

T: 0121 517 0510
E: support@inform.physio

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Coronavirus (COVID-19)Symptom Tracker

Coronavirus (COVID-19)
Symptom Tracker