covid-check

Covid-19 Patient Screening Form
Patient's name

First Name Last Name
Email
example@example.com
Do you/have they have a fever, or have you felt hot or feverish recently? (14-21 days)

Yes No
If their temperature was taken, was it over 37.8 degrees?

Yes No
Are you/they having shortness of breath or other breathing difficulties?

Yes No
Do you/they have a new continuous cough?

Yes No
Does anyone in your household have a new continuous cough or high temperature?

Yes No
Any flu like symptoms:-
Gastro-intestinal upset?

Yes No
Headache?

Yes No
Fatigue?

Yes No
Have you/they experienced a recent loss of taste or smell?

Yes No
Are you/they in contact with any confirmed positive Covid-19 patients?

Yes No
Is their/your age over 60?

Yes No
Do you/they have any of the following: -
Heart disease?

Yes No
Kidney disease?

Yes No
Lung disease?

Yes No
Diabetes?

Yes No
Any auto-immune disorders?

Yes No
Signature

Please use a mouse, or finger, to draw your signature Clear
Date

Day Month Year
Date Hour Minutes AM/PM Option
Should be Empty: