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COVID-19 PERSONAL HEALTH QUESTIONNAIRE

PLEASE ANSWER OUR COVID-19 PERSONAL HEALTH QUESTIONNAIRE BELOW PRIOR TO YOUR APPOINTMENT WITH ONE OF OUR SURGEONS. WE THANK-YOU FOR HELPING TO KEEP EVERYONE SAFE.

    Firstname: (required)

    Surname: (required)

    Email: (required)

    Contact Number: (required)

    Today's date: (required)

    Are you currently required to be in isolation because you have been diagnosed with COVID-19? (required)

    Are you currently required to be in isolation because you are currently being tested and are awaiting results of a COVID-19 test? (required)

    Are you a close contact of someone with COVID-19? (required)

    ARE YOU EXPERIENCING ANY OF THESE SYMPTOMS? (IF YOU ANSWER 'YES' TO ANY OF THE BELOW QUESTIONS YOU MUST CONTACT THE CLINIC ON 03 9131 4484 TO DISCUSS YOUR ANSWER FURTHER)

    Fever of equal to or greater than 37.5C? (required)

    Chills or Night Sweats? (required)

    Cough? (required)

    Sore throat?* (required)

    Shortness of Breath?* (required)

    Runny Nose* (required)

    Loss or change in taste or smell? (required)

    Have you been overseas or to a known hotspot in the last 14 days? (required)

    Have you been vaccinated against COVID-19? (required)

    COVID-19 Vaccination Dose 1? (required)

    COVID-19 Vaccination Dose 2? (required)

    COVID-19 Vaccination Booster? (required)

    DOWNLOAD THE COVID-19 FORM BELOW

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