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Do you currently or have you had in the last 7 days, any symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, changes in taste or smell or any flu like symptoms? Do you currently or have you had in the last 7 days, any symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, changes in taste or smell or any flu like symptoms? Yes No

Have you been diagnosed or suspected of having any highly infectious illness in the last 7 days? Have you been diagnosed or suspected of having any highly infectious illness in the last 7 days? Yes No

Have you been advised by a doctor to self-isolate at this time? Have you been advised by a doctor to self-isolate at this time? Yes No

Please note: If you have answered yes to any of the above questions you should not attend an in person manual therapy treatment. By submitting this form you consent to the Infectious Illness policy above and have answered no to all the above questions.