COVID19 TRIAGE FORM

Covid-19 Screening Form

Please complete ALL fields, and return at least 3 days prior to your appointment
Patient's name: - *

First Name Last Name
Date of Birth *

Day Month Year

Have you tested positive for COVID-19 in the last 7 days? *
Are you waiting for a COVID-19 test or the results? *
Do you, anyone in your household, or anyone in your ‘support bubble’ have any of the following symptoms:
New, continuous cough? *
High temperature or fever (37.8 c or over); ? *
Loss of, or change in, normal sense of smell or taste? *
If a - you, b – anyone in your household, or c – anyone in your support bubble have, or, have had, possible COVID-19, are you still in the self/household isolation period? *
If you have been notified by NHS Test and Trace that you have been in contact with a person with COVID-19, are you still in the isolation period? *
If you have entered or returned to the UK in the last 14 days, are you required to self-isolate? *
Please provide as much information as possible:-
Have you had the Covid-19 vaccine? *
Date of 1st dose

Day Month Year
Date of 2nd dose

Day Month Year
Leave blank if you've only had 1st dose

Covid-19 Screening Form