COVID Questionnaire

Fill all required fields (★) to submit the form.

Patient details:

1. Do you have a symptoms of COVID-19 (fever, chills, shortness of breath, cough, sore throat, loss of smell or taste)?

No
Yes

2. Have you had close contact with confirmed COVID-19 case in ther last 14 days?

No
Yes

3. Have you been in facility/location associated with the spread of COVID-19 in the last 14 days?

No
Yes

4. Have you been advised to self-isolate or are you in quarantine?

No
Yes

5. Have you had any interstate or international travel in the last 14 days?

No
Yes

6. Are you currently awaiting COVID-19 test results?

No
Yes

7. Are you under 16 years and visiting someone who is not your parent, grandparent or sibling?

No
Yes

8. Is your temprature 37.5 or above?

No
Yes
I acknowledge for the safety of others that I have provided true and accurate details and I agree that may details can be used for contact tracing.

Captcha