SAFE WORKS SPACE – ENGLISCH

* SAFE WORK SPACE - English

For this appointment, this client is (< 70 years of age) has been screened by us and has been advised to cancel their appointment if any one of the following is applicable. • severe respiratory conditions such as cystic fibrosis and severe chronic bronchitis (COPD) • Chronic heart conditions • Type 1 diabetes • Serious kidney disorders that lead to dialysis or kidney transplant • Auto-immune disease with medication that lead to suppressed immune systems • Suppressed immune systems through Metabolic syndrome • immune disorder either innate or by ageing • Suppressed immune systems through any blood diseases • Cancer patients undergoing chemotherapy or radiotherapy • After organ transplantation • Pregnant women • BMI above 40 • HIV positive. Source RIVM - The Netherlands

Consult date
Datumnotatie:DD dash MM dash JJJJ

DD-MM-JJJJ
Safe works space user
name and/or name of company
Conditions of the treatment room
- All (active) employees are free of any COVID-19 symptoms
- All (active) employees are under the age of 70, not pregnant and don’t reside in a high risk area
- All (active) employees must at all times keep to the cleaning guidelines
Client data
Input client name or number with potentially fever determination, The current body temperature should also be recorded at this stage.
Above client declares themselves at (temporary) reception and is screened for COVID-19 related factors
- Client does not present with a fever above 38 degrees Celsius (100.4 Fahrenheit) and no other health risk like: respiratory distress, common cold, sneezing, sore throat , (dry) cough, sputum production
- Nobody in the clients household has a cold, (dry) cough or a temperature above 38 degrees Celsius (100.4 Fahrenheit)
- Client has not been in direct contact with anyone known to suffer with the COVID-19 virus
- Client has not been advised to self isolate
If anyone presents being able to answer “yes” to the above questions, the client must immediately vacate the building and contact their GP. If the client is not feeling well enough to leave or is unwilling to leave, they should be isolated directly and the national health service should be contacted.
On the basis of all given and checked information, I am, as treatment provider, making the following decision:
- I am able to, considering my ethical professional norms, treat this client
- I am unable to, considering my ethical professional norms, treat this client