Cathal Moran Knee & Shoulder Surgeon | COVID-19 Screening Questionnaire

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COVID-19 Screening Questionnaire

Dear Patient

There is an ongoing global outbreak of a novel Coronavirus (COVID-19). Our practice is adhering to guidance from the Health Protection Surveillance Centre and the HSE in containing the virus.

Due to the COVID-19 pandemic we are asking patients and carers to complete this questionnaire on before attending for your appointment. This is to ensure the safety of patients and staff.

Form

Full Name *

Email Address *

Vaccination Record

Have you received a vaccine for COVID-19? *YesNoPlease only tick Yes if you have received both doses (where applicable) of the vaccine.

COVID-19 Test

Have you previously tested positive for COVID-19? *YesNo

Date of Positive Test *

Within the last 14 days

Have you had a recent onset of any of the following symptoms; dry cough, tiredness, shortness of breath, loss of taste or smell, aches and pains, headache, sore throat, nasal congestion, red eyes, diarrhoea, or a skin rash? *YesNo

Have you been in contact with a confirmed or probable case (symptomatic) of COVID-19 in the last 14 days? *YesNoThis includes household contacts – if someone you live with is symptomatic

Have you attended a healthcare facility or where patients with COVID-19 were being treated and you have had direct contact with a COVID-19 patient? *YesNoHealthcare workers caring for COVID patients wearing PPE are exempt from this question – they are casual contacts

Have you travelled abroad in the last 14 days (this includes to the UK)? *YesNo

Please do not fill in this field.

Sports Surgery Clinic, Suite 17, Santry Demesne, Dublin 9
Tel: +353 1 526 2352 Fax: +353 1 526 2353 [email protected]

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