Questionnaire for New Patients

Full Name*

Date of Birth*

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MM

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Covid 19 questionnaire

1. Have you been Tested for Covid 19?*

2. Have you travelled overseas and/or interstate in the last 14 days?*

3. Have you come in contact with a person who has tested Covid 19 positive?*

4. Are you currently experiencing Fever, Shortness of breath, Chest pain and/or coughing?*

1. Are you on Steroids?*

2. Are you suffering from Autoimmune Disease?*

3. Do you have uncontrolled Diabetes?*

4. Undergoing Cancer Treatment / Chemo Therapy?*

5. Do you have a Weakened Immune System - Susceptible to getting the flu?*

6. Are you taking Immunosuppressive Drugs?*

7. Have you undergone any Transplant Procedures/Surgery?*

8. Do you have Athsma, Emphysema or Chronic Bronchitis?*

9. Are you suffering from Lung Disease or Lung Related issues?*

10. Are you suffering from Heart Disease - Vascular Heart Disease or Valve Replacement?*

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