COVID-19 Assessment Form
Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please confirm if you are currently experiencing any of the symptoms stated below
Do you have a fever or high temperature (greater than 37.5)?
Yes
No
Do you have a cough or any other respiratory signs?
Yes
No
Do you feel extremely tired/fatigue or muscle ache?
Yes
No
Have you lost your smell and/or taste?
Yes
No
Have you been hospitalised in the last 10 days ?
Yes
No
Have you returned to the UK in the last 10 days?
Yes
No
Have you been in contract with anyone who tested positive with COVID-19 within the last 10 days?
Yes
No
Are you an NHS front-line worker or a carer?
Yes
No
Do you live with a vulnerable person?
Yes
No
Are you currently pregnant?
Yes
No
Are you over 70 years old?
Yes
No
Is your BMI over 39?
Yes
No
Do you have any of the following health condition?
Blood circulation problem (DVT, high blood pressure, embolism, CVA)
Heart condition
Diabetes
Cancer
Supressed immune system
Any respiratory condition
Any other long term health related problem
Post COVID-19 symptom
When is the last time you took COVID-19 test?
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
Leave blank if none
When was your first vaccination?
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
Leave blank if none
When was your second vaccination?
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
Leave blank if none
Please write if you have any other concern about your health here
Submit
Should be Empty: