COVID-19 CLIENT SCREENING QUESTIONNAIRE
· Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, or flu like symptoms now,
or in the past 14 days?
Yes / No
· Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?
Yes / No
· Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days?
Yes / No
· Have you been advised by a doctor to self-isolate at this time?
Yes / No
· Have you been advised by a doctor to cocoon at this time?
Yes / No
· Have you traveled anywhere nationally (more than 20km) or internationally to countries not on the Covid
green list in the last 14 days?
Yes / No
CLIENT’S FULL NAME: …………………………………………………………………
DATE of attendance at clinic: ……………………………………………………..
CLIENT’S/Parent’s/Guardian’s SIGNATURE: ……………………………………………………
CLIENT’S ADDRESS: …………………………………………………………………….
……………………………………………………………………………………………………