McCloy Dental | COVID-19 Screening Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
1. What is your COVID-19 vaccination status?
*
Partially vaccinated (1st dose only)
Fully vaccinated (2 doses)
Fully vaccinated (2 doses + booster)
Unvaccinated
Unvaccinated due to medical reasons
2. Have you been feeling unwell?
*
Yes
No
OR have you had any of the following symptoms?
*
Fever or temperature now or in the past 3 days
Sore throat, cough or shortness of breath
Runny/stuffy nose or other respiratory symptoms
Loss of smell or taste
No symptoms
3. Have you, or a person with whom you live, been asked to quarantine due to:
*
Attending an area identified as high risk for community transmission
Interstate or international travel
No symptoms
If YES, when does your quarantine period end?
4. Have you, or a person with whom you live, been asked to self-isolate while waiting for COVID-19 test results?
*
Yes
No
5. Do you, or a person with whom you live, work in a medi-hotel used for quarantine?
*
Yes
No
6. Are you, or a person with whom you live, an essential worker who is travelling interstate? (e.g. freight, transport, removalists, aircrew)
*
Yes
No
Submit
Should be Empty: