COVID-19 Screening Questionnaire

Have you or have you been in contact with anyone who has been diagnosed with Coronavirus in the last 14 days?*

Have you been in contact with anyone who has Self Isolated in the last 14 Days?*

Have you travelled outside of the UK in the last 14 Days?*

Have you experienced any cold or flu-like symptoms in the last 14 days including: Do you have a new continuous cough?*

Have you become breathless, or are you more breathless than usual? Do you struggle to breathe?*

Do you have a high temperature (fever)? If you don’t have a thermometer do you feel hot to touch on your chest or back?*

Have you experienced loss of taste and smell?*

Are you 70 OR OLDER with Cardiac Problems or Respiratory Problems or Diabetes?*

Patient (or parent/guardian) digital signature*

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