Child's Name

Therapy Group

Early Intervention 1Early Intervention 2

Address

Parent/Gaurdian

Name

Mobile

Email

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

YesNo

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?

YesNo

How is your child feeling now? Healthy and Well?

wellunwell

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

YesNo

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

YesNo

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.