COVID-19 Questionnaire

Prior to attending your appointment, please answer Yes or No to the below questions and provide any relevant comments.

Please Proceed to answer the below questions

  • Name & Email
  • Covid Questionnaire - Step 1
  • COVID Questionnaire - Step Three

Covid-19 Questionnaire

First & Last Name

Email Address

Step 1 COVID Questions

Do you have any condition or illness whereby your immunity might be compromised (cancer, diabetes etc)?

Does anyone you live with, or have regular contact with, have an illness whereby their immunity might be compromised (cancer, diabetes etc)?

Have you tested positive for Covid-19 in the last 14 days?

If you answer “Yes” to any of these questions, you may be asked to delay your appointment and come into the practice when the risk of Covid-19 infection to you is less. Virus infection is potentially more severe and dangerous for you; so try to stay at home for now.

Step Two - Covid Questions

Have you had a fever (>37.3°C), cold, dry cough, shortness of breath, muscle pain or headache in the last 14 days?

Have you been in contact with someone with these symptoms in the last 14 days?

Have you visited a high-risk area or quarantine zones in the last 14 days?

Have you been in contact with anyone with confirmed Covid-19/ Coronavirus?

Have you been in close contact with people with a severe respiratory condition in the last 14 days?