Colour Specialists

COVID-19 Pre-Appointment Questionnaire

Please can you answer all questions truthfully, this will ensure that we can maintain a safe working environment.

Please answer yes or no:

1. Are you currently suspected of having COVID-19?

2. Have you been in contact with or are living with someone suspected or confirmed of having Covid-19?

3. Do you have a fever, or have you had a high temperature in the last 14 days (a fever is a temperature

greater than 37.8c?

4. Have you had a loss of or change in your normal sense of smell?

5. Have you had a cough or any other respiratory signs in the last 14 days?

6. Do you suffer from any of the following?

Please tick Yes/No if you have any of the following:

Diabetes

Cardiovascular disease, including hypertension

Chronic lung disease

Immunodeficiency

Cancer - under active treatment?

12. Are you pregnant?

13. Are you over 70 years of age?

Please alert us of additional information if you feel it appropriate.