Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Have you previously been diagnosed with COVID-19, or do you think you’ve had/have COVID-19?

Yes

No

Have you been contacted by the NHS Track & Trace service?

Yes

No

Do you have a fever or felt/feverish in the past 14-21 days?

Yes

No

Are you having shortness o breath or difficulites breathing?

Yes

No

Do you have a cough?

Yes

No

Do you have any other flu symptoms? E.g. gastro-intestinal upset, headache fatigue?

Yes

No

Have you suffered from a recent loss of taste or smell?

Yes

No

Have you been in contact with any person with confirmed COVID-19?

Yes

No

Are you over 60?

Yes

No

Do you have heart, kidney disease?

Yes

No

Do you have diabetes?

Yes

No

Do you have auto-immune disorder?

Yes

No

Are you taking any immunosuppressive medication? Example include Methotrexate, Azathioprine, high dose steroids, etc.

Yes

No

Have you travelled to any region affected by COVID-19 in the past 14 days?

Yes

No

Do you consent to receiving treatment during COVID-19 pandemic?

Yes

No