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:
Cardiovascular disease, including hypertension
Chronic lung disease
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.