COVID19Screening

1

Patient Name: * This field is required.

First Name

Last Name

2

Title* This field is required.

3

Address* This field is required.

Street Address

Street Address Line 2

City

County

Postal Code

Country

4

Phone Number* This field is required.

Area Code

Phone Number

5

E-mail* This field is required.

6

1. Have you or have you been in contact with anyone who has been diagnosed with Coronavirus in the last 14 days? * This field is required.

YESNO

7

2. Have you been in contact with anyone who has Self Isolated in the last 14 Days? * This field is required.

YESNO

8

Have you experienced any cold or flu-like symptoms in the last 14 days?* This field is required.

YESNO

9

Do you have a new continuous cough? * This field is required.

YESNO

10

Have you become breathless, or are you more breathless than usual? * This field is required.

YESNO

11

Do you struggle to breathe? * This field is required.

YESNO

12

Do you have a high temperature (fever)? * This field is required.

YESNO

13

If you don’t have a thermometer do you feel hot to touch on your chest or back? * This field is required.

YESNO

14

A sore throat, a tacky throat or soreness when swallowing food? * This field is required.

YESNO

15

Have you experienced loss of taste and smell* This field is required.

YESNO

16

Are you too ill to do your usual daily activities? * This field is required.

YESNO

17

Are you feeling more confused than normal? * This field is required.

YESNO

18

Are you 70 OR OLDER with Cardiac Problems or Respiratory Problems or Diabetes? * This field is required.

YESNO

19

Have you been advised that you need to be shielded? * This field is required.

YESNO

20

Signature* This field is required.

Clear

21

Date* This field is required.

Date

22

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