Covid-19 Screening Questionnaire

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our staff and patients, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.

Have you or have you been in contact with anyone who has been diagnosed with Coronavirus in the last 14 days?

Have you been in contact with anyone who has Self Isolated in the last 14 Days?

Have you experienced any cold or flu-like symptoms in the last 14 days including a new continuous cough?

Have you become breathless, or are you more breathless than usual? Do you struggle to breathe?

Do you have a high temperature (fever)? If you don’t have a thermometer do you feel hot to touch on your chest or back?

A sore throat, a tacky throat or soreness when swallowing food?

Have you experienced loss of taste and smell?

Are you too ill to do your usual daily activities?

Are you feeling more confused than normal?

Are you 70 or older with cardiac problems or respiratory problems or diabetes?

Have you been advised that you need to be shielded?

Your Signature

Alternatively, if you prefer to post your form then you can download and print it.

17-18 The Waterfront,

Sovereign Harbour,

Eastbourne,

East Sussex

BN23 5UZ

info@harbour-orthodontics.co.uk

Phone 01323 472100

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