Respiratory Screening Questions Name* First Last Date of Completion* DD slash MM slash YYYY Triage Form Completed by: Vaccination Status: Yes No The below is to check if Patient currently has any of the following symptoms now or in the last 4 weeks: Advise Patient to contact us if they develop any of these symptoms within 48 hours of the appointment to ensure that they are still eligible to attend.Have you or someone in your household experienced any of the below symptoms in the last 14 days?• High temperature • A new continuous cough • Loss of, or change in, your normal sense of taste and/or smell • Sore Throat Yes No Have you or someone in your household tested positive for COVID-19 in the last 14 days? Yes No Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days? Yes No Have you travelled outside the UK in the last 14 days?(not including countries specified by the government as exempt from isolation requirements) Yes No Are you or someone in your household waiting for a result from a COVID-19 test? Yes No Have you been isolating with a suspected case of COVID-19 in the last 14 days? Yes No Have you ever had COVID-19? Yes No If YES, When?
