Patient's Name (required)
Patient's Email (required)
Do you have any of the following:
new onset of cough
new unexplained fatigue or malaise
shortness of breath
worsening of chronic cough
new loss or decrease in your normal sense of taste or smell
If you can answer YES to any of the above, please write the details below. If you can answer NO to all of the above then please state so below.
To assess which risk group you currently belong to, please tick the boxes that are relevant to you:
cardiovascular diseasediabeteschronic respiratory diseasehigh blood pressurecurrent treatment for cancertaking immuno-suppressant medicationpregnantover age of 70none of the above
Please state you are happy to attend for a face-to-face appointment having considered the above risk factors?
Have you travelled in the last 14 days outside the country or had close contact with anyone who has travelled in the past 14 days?
Have you had close contact with respiratory illness or a confirmed or probable/suspected case of COVID-19 in the past 2 weeks?
If you did, did you wear the recommended PPE according to the type of duties you were performing (eg. goggles, mask and gown or N95 with aerosol generating medical procedures? (if not applicable please state so)
Please complete the check box below (anti spam measure) and press the send button so we can receive your questionnaire. Thank you for your time.
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