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COVID-19
Homecare
The following form must be completed prior to your visit.
Please leave blank:
Full Name:
Email Address:
Mobile Contact Number:
Date of Birth:
Have you or anyone in your houshold had any of the following signs or symptoms in the last 14 days?
New, continuous cough?
Yes
No
Fever or high temperature?
Yes
No
Flu like symptoms? (vomiting, headache, muscle ache, fatigue):
No
Yes
Shortness of breath?
Yes
No
Loss or change in sense of taste or smell?
Yes
No
Been told to self isolate?
No
Yes
Have YOU had or been in close contact with a confirmed or suspected COVID-19 infection in the last 14 days?
Yes
No
Are you shielding or vunerable?
Low Risk
Vulnerable
Shielding with letter
Shielding no letter
MEDICAL HISTORY
Please check either No or Yes for the following questions. If answering Yes, please give further details in the space provided.
Do you suffer from, or have you ever had any of the following conditions?
Heart Condition:
No
Yes
Heart Condition Details:
High Blood Pressure:
No
Yes
Blood Pressure Details:
Asthma:
No
Yes
Asthma Details:
Chest Condition:
No
Yes
Chest Condition Details:
Liver Disease:
No
Yes
Liver Disease Details:
Diabetes:
No
Yes
Diabetes Details:
Kidney Disease:
No
Yes
Kidney Disease Details:
Epilepsy/Convulsions:
No
Yes
Epilepsy Details:
Cancer:
No
Yes
Cancer Details:
Are you pregnant or breastfeeding:
No
Yes
Pregnancy Details:
Are you taking any medication:
No
Yes
Medication Details:
Do you have any Allergies:
No
Yes
Allergies:
Do you use any tobacco or electronic vaping products?
No
Yes
Number per day on average
Cigarettes
Cigarettes, Number per day on average:
Cigars
Cigars, Number per day on average:
Rolling tobacco
Rolling tobacco, Number per day on average:
Chewing tobacco
Chewing tobacco, Number per day on average:
Nasal snuff
Nasal snuff, Number per day on average:
Vape
Vape, Number per day on average:
Do you drink alcohol:
No
Yes
Regular consumption (units per week):
Please give any further information relating to your medical history that may be important:
Confirmation:
I confirm that the information provided is correct to the best of my knowledge and can be incorporated into my medical records. If completed on behalf of a family member or friend you have their permission to submit these detils.
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