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Therapy for Life > Check-in

Find Us

Mount Gambier
Shop 2, 1 Compton Street
Mount Gambier, SA 5290

Millicent
Physiotherapy Department,
Millicent Hospital, Mt Gambier Rd
Millicent SA 5280

Contact
Ph: (08) 8724 8114
Fax: (08) 8724 8144
Post: P.O. Box 1403 Mt Gambier SA 5290

Hours
Monday—Friday: 8:30AM–5:00PM

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Entry Questionaire

To facilitate a safe space for you at Therapy for Life, we ask you to fill out this questionaire directly before your arrival. If you have difficulty, please contact us before you come in. We understand that this can be inconvenient, but it is important to keep yourself and others safe. The information provided here is not stored on this server, but is sent directly to the reception staff.

Have you had at least two TGA approved COVID-19 vaccinations?*

Yes

Prefer not to say

Have you had close contact with a confirmed case of COVID-19 in the last 14 days?*

Yes

Have you recently travelled interstate or overseas?*

Yes - Border Bubble

Yes - Other

Have you been told by any State Department of Health to isolate in the last 14 days?*

Yes

Have you visited any exposure sites in the last 14 days?*

Yes

Have you been tested for COVID-19 in the last 14 days?*

No - I have not had a test

Yes - My result was Negative

Yes - I am waiting for my results

Yes - My result was Positive

Do you have any new symptoms of fatigue?*

Yes

Do you have any new symptoms of shortness of breath or difficulty breathing?*

Yes

Do you have any new symptoms of headache?*

Yes

Do you have any new symptoms of runny nose?*

Yes

Do you have any new symptoms of unexplained loss of appetite?*

Yes

Do you have any new symptoms of painful swallowing?*

Yes

Do you have any new symptoms of sore throat?*

Yes

Do you have any new symptoms of a loss of taste or smell?*

Yes

Do you have any new symptoms of coughing?*

Yes

Do you have any new symptoms of nausea, vomiting or diarrhoea?*

Yes

Do you have any new symptoms of chills or fever over 37.5ºC?*

Yes

Your first name only please*

Your scheduled appointment time

AM/PM

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