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COVID-19 Health Screening
This Symptom Survey must be completed and returned prior to your appointment. It is critically important that everyone attending the clinic is healthy and symptom free. Please complete this brief survey.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
SYMPTOMS
Are you currently experiencing any of these symptoms or have you experienced any of these symptoms in the last 48 hours? **If you answer yes to any of these questions, please do not attend the clinic, contact 03 5147 1398 to change your appointment to telehealth or to cancel (cancellation fee of under 48 hours will apply) Please note that if you attend and are unwell, your appointment will be cancelled immediately and the full fee for the appointment will be charged.
Upper respiratory symptoms (ie blocked or runny nose) Child/Young Person/Client
Yes
No
Upper respiratory symptoms (ie blocked or runny nose) Parent/Carer attending with child
Yes
No
Not Applicable
Nausea (Child)
*
Yes
No
Nausea (Parent/Carer attending with Child)
*
Yes
No
Not Applicable
Vomiting/Diarrhea (Child/Young Person/Client)
*
Yes
No
Vomiting/Diarrhea (Parent/Carer attending with child)
*
Yes
No
Temperature above 37.5 C (Child/Young Person/Client)
*
Yes
No
Temperature above 37.5 (Parent/Carer attending with child)
*
Yes
No
Not Applicable
Cough (Child/Young Person/Client)
*
Yes
No
Cough (Parent/Carer attending with child)
*
Yes
No
Not Applicable
Shortness of Breath (Child/Young Person/Client)
*
Yes
No
Shortness of Breath (Parent/Carer attending with child)
*
Yes
No
Not applicable
Have you recently been tested for COVID-19 and are awaiting results? (Child/Young Person/Client)
*
Yes
No
Have you recently been tested for COVID-19 and are awaiting results? (Parent/Carer attending with child)
*
Yes
No
Not Applicable
Have you been in close contact with someone with a confirmed diagnosis of COVID-19 or is being tested for COVID-19?
*
Yes
No
Vaccination Status
Please complete vaccination status for CLIENTS over 12 attending the rooms
Double dose
Single dose
Unvaccinated
Please complete vaccination status for PARENTS/CARERS attending the rooms
Double Dose
Single Dose
Unvaccinated
Submit
Signature
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