Covid Screening Questionnaire

Covid Screening Questionnaire

Please complete all sections as accurately as possible
**If any of your responses change after completing this form, please notify our clinic before attending your appointment to discuss.**
Note: If someone will be accompanying you to your appointment, they will also have to complete a series of Covid-19 related questions later in this form. You may need to contact them while completing this form to answer these questions on their behalf.
First Name*
Middle Name
Last Name*
Date of Birth*

DayMonthYear
Are you experiencing any cold and flu like symptoms (i.e. fever, cough, sore throat or shortness of breath)?*

YesNo
What symptoms are you experiencing (please describe)?*
In the last 7 days, have you been a "close contact" with anyone with confirmed or expected Coronavirus (COVID19)?*

YesNo
Do you have any other reason to believe you have been exposed to Coronavirus?*

YesNo
Please describe why you believe you have been exposed to Coronavirus:*
Have you, or any member of your household undertaken a test for Coronavirus (Covid-19)?*

Yes - meYes - other member of my householdNo
What were the results of this test? Select all that apply*

Unknown/awaiting resultsPositive for Covid-19Negative for Covid-19
What date did you undergo your test?
Will anyone be accompanying you to your appointment? Note: If yes they will need to complete the following questions:

YesNo
Accompanying members Covid-19 declaration

The following questions are to be completed by the person accompanying you to your appointment:
First Name
Last Name
What is your current vaccination status:*

Double vaccinated plus boosterDouble vaccinated without boosterSingle vaccinationUnvaccinatedOther
Relation to patient:
Are you experiencing any cold and flu like symptoms (i.e. fever, cough, sore throat or shortness of breath)?*

YesNo
What symptoms are you experiencing (please describe)?*
In the last 7 days, have you been a "close contact" with anyone with confirmed or expected Coronavirus (COVID19)?*

YesNo
Do you have any other reason to believe you have been exposed to Coronavirus?*

YesNo
Please describe why you believe you have been exposed to Coronavirus:*
Have you, or any member of your household undertaken a test for Coronavirus (Covid-19)?*

Yes - meYes - other member of my householdNo
What were the results of this test? Select all that apply*

Unknown/awaiting resultsPositive for Covid-19Negative for Covid-19
What date did you undergo your test?
*End of accompanying members questions*
Signature (left mouse click and drag to sign)

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Covid Screening Questionnaire

Accompanying members Covid-19 declaration