Covid pre-screening questionnaire

Hi! This is a quick,simple and safe way to help us collect some details about you. The information you supply is fully encrypted, securely stored and used strictly in within the terms of our privacy policy.

Privacy Statement

This form asks you to provide certain personal data (for example, some details of your health history). We will use this information to help provide you with safe and effective health services, to contact you when necessary about your treatment, appointments and visits, and to monitor how our services are accessed and used.
We respect your privacy and the privacy of your data. The information entered into this form is securely encrypted and cannot be seen by anyone else. Your personal data is never passed to third parties for their own marketing, sales or promotion. We have strict arrangements with companies who process your data on our behalf.

Your contact details

First, let's get some basic details so we know who you are!

Title

First Name

Last Name

Have you tested positive for COVID-19 in the last 7 days?

YesNo

Are you waiting for a COVID-19 test or the results?

YesNo

Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?

YesNo

Have you been notified by NHS Test & Trace in the last 14 days that you are a contact of a person who has tested positive for Covid-19 and you do not live with that person?

YesNo

Do you have a new, continuous cough?

A new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If you usually have a cough, it may be worse than usual.

YesNo

Do you have a high temperature or fever?

YesNo

Do you have the loss of, or change in, your sense of smell or taste?

YesNo

That's great - we're finished! Please sign the form to confirm that your information is completed.

Signature

Use a finger, stylus or mouse to sign your name.