Which category below would you put yourself into for exposure to Covid 19 in the last month.
High risk - Frontline health worker or carer or confirmed case of Covid 19 in your own householdModerate risk - Keyworker in contact with the public, but have had no symptoms or exposure to someone who has been infected.Low risk - Have been isolating alone or with household and with minimum public contact. No known cover 19 exposure.Have had Covid 19 and recovered, and this was confirmed by testing and documentationHave an underlying Health condition that puts you in a Vulnerable category
Has anyone in your household tested positive for Covid 19? YesNo Is anyone isolating your household? YesNo
Have you or anyone in your household experienced any of these symptoms in the last 3 weeks:
Shortness of breath or difficulty in breathing, that is new or different than before YesNo New and persistent cough YesNo Temperature over 37.8 celsius/100 fahrenheit or a Fever YesNo Unexplained tiredness/lethargy YesNo Loss of taste or smell YesNo Muscles aching, that is new to you YesNo Stomach upset problems that are new to you YesNo Are you over 70 years old? YesNo
Medical Questionnaire
Are you currently receiving treatment from a doctor, hospital or clinic? YesNo Do you carry a Medical warning card? YesNo Are you diabetic (or is anyone in your family)? YesNo Do you suffer from any allergies to medicines (e.g. penicillin), food or substances (e.g. latex/rubber)? YesNo Do you suffer from Hayfever/Eczema? YesNo Do you suffer from Bronchitis, asthma or other chest conditions? YesNo Do you suffer from fainting attacks, giddiness, blackouts or Epilepsy? YesNo Do you suffer from Heart problems, Angina, blood pressure problems or Stroke? YesNo Do you suffer from Arthritis? YesNo Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? YesNo Do you suffer from any infectious diseases (including HIV and Hepatitis) YesNo Have you ever had Rheumatic fever or Chorea? YesNo Have you ever had Liver disease (e.g. jaundice,hepatitis) or kidney disease? YesNo Have you ever had blood refused by the Blood transfusion service? YesNo Have you ever had a bad reaction to a general or local anaesthetic? YesNo Have you ever had joint replacement or other implant? YesNo Have you ever had treatment that required you to be in hospital? YesNo Do you have any close relatives with Creutzfeldt Jacob disease (mad cow disease)? YesNo Have you ever had Heart surgery? YesNo Have you ever had Brain surgery? YesNo
Do you Vape with an E-Cig? YesNo
