Covid-19 Triaging Questionnaire Your Details Prefix Mr. Mrs. Miss Ms. Dr. First Name * Surname * Date of Birth * Email * Home Phone Mobile COVID-19 Risk Assessment Do you or any member of your household have COVID-19 or are you waiting for a COVID-19 PCR test result (not a routine surveillance test result)? * No Yes Are you required to self-isolate (including arrival from overseas)? * No Yes Do you have ANY of the following symptoms now, or in the last 14 days? * Fever, acute cough or shortness of breath Muscle aches, loss of smell, sore throat Generally feeling unwell with no other likely diagnosis None Do you have any other reason to think that you are at risk of having COVID-19? No Yes Consent * I confirm that the information above is true and correct to the best of my knowledge Thank you for completing the form.
