Date of Birth:
Do you have a confirmed diagnosis of COVID-19?
YesNo
Are you waiting for a COVID-19 test?
Are you awaiting the results of a COVID-19 test?
Have you returned from overseas travel in the last 14 days?
Have you had contact with someone with a confirmed diagnosis of COVID 19, or been in isolation with a suspected case in the last 14 days?
Do you have any of the following symptoms?
Cough
Sore Throat
Fever
Shortness of Breath
Running Nose
Sneezing
Post-nasal drip
Loss of Smell
Loss of Taste
Parent:
Guardian
Patient
Date:
