COVID-19 symptom checker

This form must be utilised to ensure that you are free from COVID-19 symptoms and pose limited risk to others *Required

DateTime

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Are you currently diagnosed with or believe you may have COVID

Have you had any of these symptoms of COVID19 in the past 14 days?

High temperature (fever)

A new continuous cough

New unexplained shortness of breath

Have you been in contact with a COVID19 confirmed or suspect case in the previous 14 days

If you have answered YES to any of these questions you should stay at home and inform your line manager and medical practitioner. You should follow your territories current Public Health guidance.

Signature

Please note the next question is only for medical personnel

Have all infection prevention measures been implemented with the addition of the appropriate Personal Protective Equipment when reviewing patients with confirmed or suspected COVID-19 in the previous 14 days?