Patient Corona Virus Questionnaire 2020

Patient's first name*
Patient's last name*
Patient Appointment Date*
Patient Appointment Time*
Email*
Phone*
1. Do you have or have had a fever in the last 2 weeks?
2. Do you have or have had a cough in the last 2 weeks?
3. Do you have or have had a sore throat in the last 2 weeks?
4. Do you have or have had shortness of breath in the last 2 weeks?
5. Have you been exposed to someone with any of the above in the last 2 weeks?
6. Have you travelled outside of Queensland in the last 2 weeks
7. Have you been exposed to a confirmed COVID-19 case or someone associated with them?
Are you attending this appointment alone? *

I have read and understood the above and I am aware it is a CRIMINAL offence to supply misleading information and Qld Health will be notified.

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