COVID-19 Medical ScreeningPlease submit this screening form before attending your appointment Existing Patient Medical Questionnaire COVID-19 SCREENING Name * First Name Last Name Date of Birth (DD/MM/YYY) * Have you felt hot/feverish recently (in the last 14 days)? * Yes No Have you experienced any shortness of breath? * Yes No Do you have a persistent cough? * Yes No Are you experiencing any flu-like symptoms / gastrointestinal upset / headache / fatigue? * Yes No Have you experienced a recent change in taste or smell? * Yes No Have you been in contact with any confirmed COVID-19 positive patients in the past 14 days? * Yes No Have you travelled outside the UK in the past 14 days? * Yes No Do you have any chronic medical conditions? * Yes No Are you pregnant? * Yes No N/A Have you previously been diagnosed with COVID or suspect you may have had COVID? * Yes No Not Sure Would you be interested in COVID antibody testing? * Yes No Have you experienced any changes to your health/started new medications since your last appointment * Yes No If yes, please specify: Thank you for completing our screening form! If you have any questions or concerns please do not hesitate to call or email us. See you soon!
