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Covid-19 Screening Form :: Annelene Naidoo

Please fill out the below form ahead of your session with Annelene Naidoo.

Name *

First

Last

ID Number *

Email *

Date Completed *

Physical Address *

Postal Address *

Employer and Work Address *

Telephone Number *

Mobile Number *

I have a fever/chills *

Yes
No

Please select yes/no regarding the above statement

I have a cough *

Yes
No

Please select yes/no regarding the above statement

I have shortness of breath *

Yes
No

Please select yes/no regarding the above statement

My eyes are red *

Yes
No

Please select yes/no regarding the above statement

I have a sore throat *

Yes
No

Please select yes/no regarding the above statement

My body aches *

Yes
No

Please select yes/no regarding the above statement

I have lost my sense of smell and or sense of taste *

Yes
No

Please select yes/no regarding the above statement

I have nausea/vomiting/ diarrhea *

Yes
No

Please select yes/no regarding the above statement

I have been in direct contact with a person that has COVID 19 *

Yes
No

Please select yes/no regarding the above statement

I have been to a care facility in the past 14 days where patients with confirmed COVID19 have been treated *

Yes
No

Please select yes/no regarding the above statement

I have tested positive for COVID 19 in the past 10 days *

Yes
No

Please select yes/no regarding the above statement

I am currently under investigation for having psooible COVID 19 *

Yes
No

Please select yes/no regarding the above statement

Please note that your temperature will be taken at the practice upon your arrival.

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