Covid-19

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)

YesNo

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

YesNo

Have you been directed to a period of 14-day quarantine by the DHHS as a result of being a close contact of someone with COVID-19? (required)

YesNo

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)

YesNo

Chills or Night Sweats? (required)

YesNo

Cough? (required)

YesNo

Sore throat?* (required)

YesNo

Shortness of Breath?* (required)

YesNo

Runny Nose* (required)

YesNo

Loss or change in taste or smell? (required)

YesNo

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

YesNo

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

YesNo

COVID-19 Vaccination Dose 1? (required)

YesNo

COVID-19 Vaccination Dose 2? (required)

YesNo

COVID-19 Vaccination Booster? (required)

YesNo

COVID-19 PERSONAL HEALTH QUESTIONNAIRE

DOWNLOAD THE COVID-19 FORM BELOW