Do you have a confirmed diagnosis of COVID-19?

Yes

No

Are you suspected to be COVID-19 positive?

Yes

No

Do you exhibit any acute respiratory infection with at least one of the following symptoms:

Cough

Sore throat

Shortness of breath

Anosmia (loss of sense of smell)

Coryza (Head cold eg. runny nose, sneezing, post nasal drip)

I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in strictest confidence and it is my responsibility to inform this office of any changes to my medical status.

Have you, or anyone coming in contact with you, had contact with someone with a confirmed or suspected diagnosis of COVID-19 in the last 14 days?

Yes

No

With Fever

Yes

No

Have you been overseas in the last 14 days?

Yes

No

Name*

Email*

Phone*

Date

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COVID-19 medical history questionnaire

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COVID-19 medical history questionnaire

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Free Consultation