Covi
d
-
19 Patien
t Screen
ing Form
Patient's name
First Name
Last Name
Email
example@example.com
1 - Do you have any of the following symptoms?
High temperature or fever?
Yes
No
New, continuous cough?
Yes
No
A loss or alteration to taste or smell?
Yes
No
2 - Have you or any member of your household/ family had a confirmed diagnosis of Covid-19 in the last 10 days?
Yes
No
3 - Are you or any member of your household/ family waiting for a Covid- PCR test result?
Yes
No
4 - Have you travelled internationally in the last 10 days to a country that is on the government red list?
Yes
No
5 - Have you or any member of your household/ family been advised to isolate by any NHS organisation in the last 10 days?
Yes
No
Signature
Please use a mouse, or finger, to draw your signature
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Minutes
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AM/PM Option
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Submit
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