Covid 19 Questionnaire Form

Full Name *

Mobile/Home Phone *

Email

Do you currently have any flu like symptoms (i.e cough, runny nose, fever, sore throat) or shortness of breath? *

Yes

No

Have you been unwell in the last 14 days? *

Yes

No

In the past 14 days, have you visited any of the COVID19 hotspots? If unsure, please check at bit.ly/NSWHotspot *

Yes

No

If you answered yes to the above, please specify location and date of visit?

Are you in close contact or living with any persons who have either recently come back from COVID19 hotspots or have been ill in the last 14 days? *

Yes

No

Have you been in close contact with a person with confirmed COVID19 in the last 14 days? *

Yes

No

Have you been tested for COVID19? (Please note your appointment may be cancelled/rescheduled if you do not have a test result within 48hours prior to the appointment) *

Yes

No

If you have been tested for COVID19, do you have the results? *

Yes

No

If you have received the results, is it: *

Positive

Negative

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