COVID19 Patient Risk Assessment Questionnaire

In order to complete our new paperless journey, we would appreciate you completing the following questionnaire to allow us to determine the best route to treatment for you.

Your Details:

DATE OF BIRTH

What is your preferred method of contact?:

Have you tested positive for COVID-19 in the past 7 days?:

Are you awaiting a COVID-19 test or test results?:

Do you have ANY of the following symptoms?:

1. New continuous cough (coughing for longer than an hour or 3+ coughing episodes in any 24 hour period);

2. A high temperature or fever;

3. A loss or change in smell or taste.

Do you live with someone who has tested positive for COVID-19 in the last 14 days?:

Please note: all questions need to be answered.