COVID19 Questionnaire
It is important to us that this form is completed in full, failure to complete the form will result in us not being able to see you for your appointment. We kindly ask that this form is completed prior to your appointment date.
Name
First Name
Last Name
Date of Birth
Address
Contact number
Do you have a new persistent cough or a fever, temperature over 37.8?
Yes
No
Have you been in contact with anyone in the last 14 days that has/had the COVID19 virus? (including any family members)
Yes
No
Have you or your family members been told to self isolate in the last 14 days?
Yes
No
In the last 14 days, have you had any other symptoms related to COVID19?
Yes
No
If yes, please specify below
Please insert N/A if applicable
According to government guidelines, would you consider yourself to be either vulnerable, medically compromised or shielding at home during lockdown (including any family members)?
Yes
No
If you selected yes, please give details below:
If you selected no, please insert N/A in the box above
Do you have any changes to your current Medical History?
YES
NO
If yes, pleases specify below
Insert N/A if no changes to your Medical History
Signature
Date
Submit
Should be Empty: