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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.