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:

 

Confirmed or probable COVID-19 case

 

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

 

Are you a probable COVID-19 case?
Yes / No

 

Are you required to self-isolate and/or waiting for COVID-19 test results?
Yes / No

 

Unknown COVID-19 status – Clinical criteria

 

Do you have new or worsening respiratory symptoms including one of the following: new or worsening cough, sneezing and runny nose, sore throat, fever, temporary loss of smell or altered sense of taste, shortness of breath?
Yes / No

 

Do you have any of the less common symptoms, such as: diarrhoea, headache, muscle aches, nausea, vomiting, malaise, chest pain, abdominal pain, joint pain or confusion/irritability – where there is no other likely diagnosis?
Yes / No

 

Additional questions: Have you:

 

Had close contact with someone who is a probable or confirmed COVID-19 case?
Yes / No

 

Been in attendance at a current location of interest?
Yes / No

 

Travelled internationally (excluding travel by air from a country/area with which New Zealand has quarantine-free travel (QFT))?
Yes / No

 

Had direct contact with someone who has travelled overseas (excluding travel by air from a QFT country/area). This includes border staff, quarantine and isolation facility staff, and international aircraft and shipping vessel crew, except those who have travelled exclusively between New Zealand and QFT destinations?
Yes / No

 

Exited an MIQ facility (excluding recovered COVID-19 cases)?
Yes / No

 

Worked on an international aircraft or shipping vessel (excluding aircraft from a QFT country/area)?
Yes / No

 

Cleaned at an international airport or maritime port in areas/conveniences visited by international arrivals (excluding areas/conveniences for travellers by air from a QFT country/area)?
Yes / No

 

Worked in cold storage areas of facilities that receive imported chilled and frozen goods directly from an international or maritime port?
Yes / No