COVID-19

Pre Appointment Questionnaire and Consent

1. Do you or anyone you live with have a confirmed positive test of COVID19 in the last 10 days or waiting for a result of a COVID19 PCR test? YesNo

2. Do you have any of the following symptoms in the past 24 hours? YesNo


- Fever or temperature that is over 37.8 degrees
- New persistent cough
- Recent loss of or changes to taste or smell
- Cold symptoms – runny nose/sneezing
- Sore throat
- Diarrhoea, nausea or vomiting
- Headache (that is not usual for you)
- Recent aches and pains

3. Have you or a member of your household been told to isolate in last 10 days? YesNo

4. Have you ever had a positive test (lab) for COVID-19? YesNo

(if yes, please record what date/s)
5. Have you had double vaccination (2) or booster and no COVID19 symptoms? YesNo

6. Have you had needed to have a PCR test or taken a LFT within the past 72 hours and isolated since the test? YesNo
(If yes, please confirm if the result was negative)

7. Have you travelled from another country outside the UK in past 10 days? YesNo

(If yes – which country and is it on the red list?)

8. Have you had contact with someone with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case in the last 10 days? YesNo

9. I understand that some people are considered to be at greater risk of serious illness or higher mortality if they contract COVID-19 and I understand that these are individuals who: I understand

- Have pre-existing medical conditions such as heart and circulatory disease.
- Have high blood pressure.
- Have diabetes.
- Are very overweight.
- Are male.
- Are over 60 years of age
- Are from a black, Asian or minority ethnic (BAME) background.

10. I consent to having treatment during COVID-19 I consent

Name (Required)

Email (Required)

Telephone Number (Required)


* By submitting this form you agree to the practice privacy policy and the website privacy policy.

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029 2066 5566
info@parksidepractice.com
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