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.

Patient risk assessment questions:


1. Do you have COVID-19 and are required to self-isolate?
Yes / No


2. Are you required to self-isolate for another reason (e.g., you live with someone who has tested positive for COVID-19)?
Yes / No


3. Do you have ANY of the following symptoms?

• Fever, acute cough or shortness of breath
• Muscle aches, loss of smell, sore throat
• Generally feeling unwell with no other likely diagnosis

Yes / No


4. Do you have any other reason to think that you are at risk of having COVID-19?
Yes / No