COVID 19 Health Questionnaire

Please complete the form before attending the clinic.

    Child's Name

    Therapy Group

    Early Intervention 1Early Intervention 2






    Has you child visited any countries outside Ireland (except Northern Ireland) in the last 14 Days?


    Does your child suffer from any of the following flu, or COVID-19 Symptoms?

    Common Symptoms

    Fever YesNo
    Dry Cough YesNo
    Tiredness YesNo

    Less Common Symptoms

    Aches and pains YesNo
    Sore throat YesNo
    Diarrhoea YesNo
    Conjunctivitis YesNo
    Loss of taste or smell YesNo
    Rash or discolouration of fingers or toes YesNo

    More Severe Symptoms

    Difficulty breathing or shortening of breath YesNo
    Chest pain or pressure YesNo
    Loss of speech or movement YesNo

    Did you consult a Doctor or other medical practitioner in the last 14 days for these, or similar symptoms?


    How is your child feeling now? Healthy and Well?


    Have you or your child been in contact with someone who has tested positive for COVID-19 in the last 14 days?


    Are you, or your child in contact with someone from a COVID-19 at risk category?


    NOTE: When on site, children will adhere to standard processes/procedures regarding infection control, i.e. hand washing/sanitising and general coughing/sneezing etiquette.

    By checking this box and submitting the form, you agree that the information provided is accurate and that you will notify Achieve Therapy of any changes to the submitted information.

    Need more info?

    If you need extra information about any of the services we offer, call the clinic at  085 1320193 or email


    To make an appointment or inquire about any of our services please contact us at 085 132 0193 or email