COVID-19 Questionnaire

Please reply by text – ‘No to all questions’ – if this is your response.

 

You will not be able to attend your appointment if the COVID-19 questionnaire answer has not been completed.

COVID-19 epidemiological questions:

 

Do you have a confirmed diagnosis of COVID-19?
Yes / No

 

Are you waiting for a COVID-19 test or the results, or considered a probable case, or been asked to self isolate?
Yes / No

 

Have you had close contact* with other people in the last 14 days who are probable or confirmed to have COVID-19?
Yes / No

 

Acute respiratory infection symptoms:

 

Do you have now or worsening symptoms of an acute respiratory infection with at least one of the following:

 

• cough
• sore throat
• shortness of breath
• runny nose, sneezing, post nasal drip (coryza)
• loss of smell (anosmia)

with or without fever?

 

Overseas travel and close contacts:

 

Have you travelled overseas in the last 14 days?
Yes / No

 

Have you had direct contact with someone in the last 14 days who has travelled overseas?
Yes / No

 

Do you work on an international aircraft or shipping vessel?
Yes / No

 

Do you work or have you recently worked at an international airport or maritime port in areas/conveniences visited by international arrivals?
Yes / No

 

Do you work or have you recently worked in customs, immigration, or at managed quarantine/isolation facilities?
Yes / No

 

Are you a household member or a community contact of aircrew?
Yes / No