Covid -19 Screening and Consent Form Name * First Name Last Name Full Adress Post Code Date of Birth Email * Mobile Number TESTING Have You Had a Covid-19 Test Yes No If Yes when? Was It An Antibody Or Antigen Test? If It Was A Positive Result Has The Isolation Period Expired? Yes No Do You Still Have Symptoms? Yes No SYMPTOMS - Are you experiencing any of the following Do You Have a New or Persistent Cough Yes No Do You Have A Fever (above 37.8 C) Yes No Have You Lost Or Experiencing a Reduced Sense Of Taste Or Smell? Yes No Have you been in contact with anyone with Covid-19 symptoms or been living in a household with someone who is self isolating due to Covid-19 symptoms? IF YES PLEASE SELF ISOLATE FOR 14 DAY Yes No CURRENT HEALTH ISSUE (Extra precautions with PPE may be required) Recently been hospitalised? Yes No If so, why? High blood pressure or other heart conditions? Yes No Diabietes Type 1 or 2 ? Yes No If yes which one? Cancer Yes No Respiratory conditions Yes No Pregnant Yes No If yes, how many weeks? Aged over 70? Yes No PREVIOUSLY CONTRACTED CORONAVIRUS (Treatment might not be possible at this stage) Are you experiencing post Covid - 19 circulatory complications (deep vein thrombosis, micro-embolisms, stroke symptoms or pulmonary embolism) Yes No EXPOSURE TO COVID -19 (Extra precautions with PPE may be required) An NHS front line worker Yes No A carer - home or care home Yes No Shielding a vulnerable adult Yes No Are you allergic to latex gloves or specific cleaning products? Yes No SIGNED I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration. If either I or someone I have been in contact with tests positive for Covid-19 or have been contacted by NHS Test & Trace I will inform you. Sign and date below Thank you!