Today's Date
Patient Name
Completed by Have you had one, two or three vaccinations? NoneOneTwoThree
1. Have you or any member of your household had COVID-19 in the last 14 days? NoYes
2. Are you required to self-isolate? NoYes
3. Have you or any family member arrived from overseas in the last 14 days? NoYes
4. Do you have ANY of the following symptoms now, or in the last 14 days? • Fever, acute cough or shortness of breath NoYes • Muscle aches, loss of smell, sore throat NoYes • Generally feeling unwell with no other likely diagnosis NoYes
5. Do you have any other reason to think that you are at risk of having COVID-19? NoYes
