Patient Name

DOB

Have you experienced ANY of the following symptoms within the last 14 days? Have you experienced ANY of the following symptoms within the last 14 days?

Temperature or feeling feverish Temperature or feeling feverish YES NO

New cough New cough YES NO

Shortness of breath Shortness of breath YES NO

Flu-like symptoms such as fatigue, headache Flu-like symptoms such as fatigue, headache YES NO

Nausea or Diarrhoea Nausea or Diarrhoea YES NO

Chills or shivering Chills or shivering YES NO

Muscle pains or rash Muscle pains or rash YES NO

Loss of taste OR smell Loss of taste OR smell YES NO

DIAGNOSIS DIAGNOSIS

Have you been diagnosed or suspected of having COVID-19 Have you been diagnosed or suspected of having COVID-19 YES NO

Have you had a throat and nasal swab? Have you had a throat and nasal swab? YES NO

Did you test Positive or Negative? Did you test Positive or Negative? POSITIVE NEGATIVE

Date of test

Have you had an antibody blood test? Have you had an antibody blood test? YES NO

Was it Positive or Negative? Was it Positive or Negative? POSITIVE NEGATIVE

Date of test

FAMILY AND CLOSE CONTACTS: FAMILY AND CLOSE CONTACTS:

Are any of your family members or immediate/close contacts currently sick or experiencing?

Fever, Cough, Shortness of breath or Flu-like symptoms? Fever, Cough, Shortness of breath or Flu-like symptoms? YES NO

Sore throat, Muscle aches, Fatigue, Nausea & Diarrhoea? Sore throat, Muscle aches, Fatigue, Nausea & Diarrhoea? YES NO

Have any of your family or immediate/close contacts been diagnosed with COVID-19? Have any of your family or immediate/close contacts been diagnosed with COVID-19? YES NO

If yes, when?

RECENT TRAVEL: RECENT TRAVEL:

Have you travelled internationally or within the UK or attended a public event in the last 15 days? Have you travelled internationally or within the UK or attended a public event in the last 15 days? YES NO

If yes, where and when?

Has any of your family or close contacts recently travelled internationally or within UK or attended an event in the last 15 days? Has any of your family or close contacts recently travelled internationally or within UK or attended an event in the last 15 days? YES NO

If yes, where and when?

PATIENT NAME

PATIENT SIGNAUTRE PATIENT SIGNAUTRE PATIENT SIGNATURE

DATE