Covid screening form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Have you had a COVID 19 test?

YesNo

When?

Date

What type of test?

Antigen (tests if positive on day of testingAntibody (possible immunity)

Has the isolation period expired?

YesNo

Do you still have symptoms?

YesNo

Do you have a persistent cough?

YesNo

Do you have a fever (above 37.8 °C)

YesNo

Have you lost or experiencing a reduced sense of taste or smell?

YesNo

Have you been in contact with anyone with COVID 19 symptoms or living in a household with someone who is self isolating due to covid-19 symptoms?

YesNo

If YES to any of the above, please follow Scottish Government guidelines and self isolate and get tested.

Have you recently been hospitalised?

YesNo

Why?

Do you have high blood pressure or a heart condition?

YesNo

Do you have any form of diabetes?

YesNo

What type of diabetes

Type 1Type 2Other

Do you have cancer?

Yesno

Do you have any respiratory conditions?

YesNo

Are you pregnant?

YesNo

How many weeks?

Are over 70?

YesNo

Are you experiencing post Covid-19 circulatory complications (Deep vein thrombosis (DVT), Micro-embolism, Stroke symptoms, or Pulmonary embolism)

YesNo

An NHS frontline worker

YesNo

A carer- home or care home

yesNo

Shielding a vulnerable adult

YesNo

Are allergic to latex gloves or any specific cleaning products?

YesNo

I solemnly and sincerely declare that the information I have provided is true and correct and as I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.

If either I or someone I have been in contact with tests positive for covid-19 or have been contactacted by NHS Test ant Trace I will inform you.

Signature (use a mouse/touchpad or a finger on touch screens)

Date

Thank you for filling in this form. Could you also please read the procedures that I must know follow before, during and after appointments and what is required of you- it's not much. Covid Procedures (opens in new tab)

Covid screening and consent

Testing

Symptoms

Current Health Issues

Previously Contracted Covid-19

Exposure to Covid-19?

Signed