COVID-19 Patient Screening Form

COVID-19 Patient Screening Form

Shiraz, 389 Warwick Road, Solihull
West Midlands, B91 1BJ
Tel: 0121 709 1660

Title *

Full Name *

First Name Last Name

Date of Birth *

Email *

Mobile *

Area Code Phone Number

Landline *

Area Code Phone Number

Pre-appointment date *

Pre-appoinment *

YES

NO

DETAILS

Have you called previously for AAA? If so insert date and advice given in the details column.

Have you been diagnosed with Coronavirus?

Are you having shortness of breath or other difficulties breathing?

Do you have a cough? Or have had a previous dry cough in the last 14 days?

Do you have, or have you felt hot or feverish recently (14-21 days)?

Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

Have you experienced recent loss of taste or smell?

Are you in contact with any confirmed COVID-19 positive patients? Patients who are well but have a sick family member at home with COVID-19 should consider postponing elective treatment.

Is your age over 70?

Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Have you travelled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

These will be checked again on the day of your appointment.

In-office date

In Office

YES

NO