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Respiratory Screening Questions for use across all health and care settings
The screening questions below apply to all service users and anyone accompanying the service user to a healthcare facility e.g. parent, carer
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* Required
Email
*
Your email
Your Name
*
Your answer
Your Contact [Landline & Mobile]
*
Your answer
Date of birth
*
Your answer
Your address with postcode
*
Your answer
Have you had a confirmed diagnosis of COVID19 in the last 10 days
*
Yes
No
Do you have any of following symptoms; HIGH TEMPRATURE OR FEVER?NEW CONTINOUS COUGH?LOSS OF TASTE OR SMELL? NEW HEADACH?NEW BLOCKED/RUNNY NOSE OR FLU? SORE THROAT? MUSCLE PAINS?NEW DIARRHOES?
*
Yes
No
Have you had a close contact with someone with a confirmed diagnosis of COVID 19 in last 10 days
*
Yes
No
If any of the above is yes and you are urgent need for treatment please describe What is your vaccination status
*
Fully vaccinated
Partially vaccinated
Non Vaccinated
Other:
A copy of your responses will be emailed to the address you provided.
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