Judy Bowen-Jones

Patient Pre-Appointment Screening & Consent Form

    Please indicate if you are the:


    PLEASE check your email is correct.

    Update from Judy Bowen-Jones:

    I am now permitted to treat patients, so long as I comply with Government guidelines for making my practice ‘Covid-19 Secure’. Under these guidelines, I am required to carry out (and keep a record of) a risk assessment/Covid-19 screening consultation with you prior to your appointment. The aims of this risk assessment questionnaire are to ensure:

    1) it would be appropriate for you to attend the clinic at this stage of lockdown, and

    2) that you understand the risks associated with coming for acupuncture at the present time

    Before your appointment, I will send you information explaining the changes I have made to my practice to help minimise the risk of Covid-19 transmission. It is important that you understand, even with the best endeavours, it is not possible to eliminate the risk of contracting Covid-19 completely.

    First, I would be grateful if you could answer some general questions:

    Your General Health

    A) What is/are your main reason(s) for seeking acupuncture at this time?

    B) Is your condition affecting your quality of life?


    C) Are you suffering from any stress or anxiety?


    D) Have you considered getting medical help?


    Covid – 19 Screening Information

    To help minimise the risk of transmission of Covid-19 at my clinic, I need to ask you some screening questions about COVID-19. Please answer Yes or No to each of the following questions:

    In the last 14 days:

    1. Have you had a high temperature? This can mean feeling hot to touch on your chest and back. You do not need to measure your temperature


    2. Have you had a new continuous cough? This means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours. If you usually have a cough, it may be worse than usual.


    3. Have you lost sensations of taste or smell?


    If you answer Yes to any of the above Q1-3, you may not attend the clinic for at least 7 days, you should self-isolate and contact NHS Test and Trace services to get tested as soon as possible*

    4. Have you had close contact (under 2 metres) with anyone with a confirmed Covid-19 diagnosis or someone exhibiting the above 3 symptoms in the last 14 days?


    If you answer Yes to Q4, you must stay at home and not leave your house for 14 days from the day that your contact first fell ill*

    5. Have you travelled abroad in the last 28 days?


    If yes, please give details here

    6. Have you been instructed by the government to quarantine?


    If yes, please give details here

    7. Have you been contacted by the government or the NHS and told to shield or self-isolate for any reason?


    If yes, please give details here

    If you answered Yes to any of Q1-7 above, you may not attend my practice at present as this may pose a risk to yourself and/or others.

    *Please note, Covid-19 guidance is continually evolving. If you answered Yes to any of these questions, I would recommend that you check the Government website regularly for updates

    Clinically Vulnerable People

    You are probably aware that people with certain health conditions, or over a certain age are more vulnerable to the effects of Covid-19. There are 2 categories of people: the clinically vulnerable and the clinically extremely vulnerable.

    Please read the following information very carefully and questions 7 & 8 below, both for yourself and anyone else you live with.

    Clinically vulnerable people

    People in this category of risk include:

    1. Anyone aged 70 and older (regardless of medical conditions)

    2. Anyone under 70 with an underlying health condition (that is, anyone instructed to get a flu jab as an adult each year on medical grounds) – such as:

    • chronic (long-term) mild to moderate respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis

    • chronic heart disease, such as heart failure

    • chronic kidney disease

    • chronic liver disease, such as hepatitis

    • chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy

    • diabetes

    • a weakened immune system as the result of conditions such as HIV and AIDS, or medicines (such as steroid tablets)

    • being seriously overweight (a body mass index (BMI) of 40 or above)

    • pregnant women

    Clinically extremely vulnerable people

    People in this category of risk include:

    1. Solid organ transplant recipients.

    2. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD).

    3. People with rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency (SCID), homozygous sickle cell).

    4. People on immunosuppression therapies sufficient to significantly increase risk of infection.

    5. Women who are pregnant with significant heart disease, congenital or acquired.

    6. Other people have also been classed as clinically extremely vulnerable, based on clinical judgement and an assessment of their needs. GPs and hospital clinicians have been provided with guidance to support these decisions.

    7. People with specific cancers:

    • people with cancer who are undergoing active chemotherapy

    • people with lung cancer who are undergoing radical radiotherapy

    • people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment

    • people having immunotherapy or other continuing antibody treatments for cancer

    • people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors

    • people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs

    More information about who has been classed as Clinically extremely vulnerable is available on the NHS website here https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/

    If someone from any of these vulnerable categories contracts COVID-19, they are more likely to have complications, and are at a higher risk of severity of disease and dying.

    If you, or anyone you live with falls into one of these categories, it is important that you are fully aware of your/their increased risk status. Any decision you make to attend must be based on your informed consent. You should think about this carefully and consult with others you live with if they are ‘vulnerable’.

    8. Do you come under the:

    clinically vulnerable category, orthe clinically extremely vulnerable categoryneither of these

    9. Does anyone you live with you come under the:

    clinically vulnerable category, orthe clinically extremely vulnerable categoryneither of these

    Informed Consent

    I, Judy Bowen-Jones, can confirm that I have complied with Government requirements: to conduct a risk assessment, and introduce new social distancing, hygiene, hand washing and PPE procedures in my practice - to limit the spread of Covid-19. During your appointment, I will need to have non-socially distanced, close contact with you to perform the treatment. While I will meet very high standards of infection protection and control. It is impossible to completely eliminate the risk.

    Please confirm that you understand this and are happy to proceed with the treatment.


    At the beginning of your appointment, you will be asked to sign a Patient Consent Form giving your informed consent to having treatment which will involve close contact.

    Prior to your appointment, I will send you an Information Sheet (PAIS) explaining the new Covid-19 procedures in place at the clinic, what to expect and how you should prepare for your treatment. You will also get a copy of the Patient Consent Form (PCS) for you to read through in advance. You do not need to print this off/bring it with you. I am required to provide you with a copy to sign at the start of your appointment. Can you confirm that you will read the documents sent to you?


    If, between now and the time of your appointment, you develop any Covid-19 symptoms or there are any changes to the points raised in the Covid-19 Screening Information questions answered earlier (symptoms, contact, vulnerability etc), it is imperative that you let me know as soon as possible and before your next appointment. Can you confirm that you understand this?


    Also, if you develop Covid-19 symptoms within 48 hours following your appointment, you must get tested as soon as possible and let me know the result immediately, as I will need to self-isolate/stop working to comply with government Test & Trace guidelines. Can you confirm that you are willing to do this?


    If I develop Covid-19 symptoms within 48 hours of treating you, I am legally obligated to inform the NHS Test and Trace service and supply them with your name, phone number, and the date and time of your recent appointment. By attending your appointment you give your consent to this. Please confirm that you understand and accept this


    If you have any questions or concerns or need help filling in this questionnaire, please do not hesitate to contact me.

    Once I have received this questionnaire back from you, I will give you a quick call to clarify any details and confirm your appointment.

    Sincere thanks for you time and co-operation,

    Warmest wishes, Judy Bowen-Jones