COVID-19 SCREENING SURVEY

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As part of the COVID-19 Safety Plan, this mandatory form must be completed by all clients before attending any in-person appointment at the practice (Joynton Avenue Creative Centre, 3A Joynton Avenue, Zetland NSW 2017). The appointment will only proceed if it is safe to do so, based on your answers in the survey. If the appointment cannot proceed, it will be cancelled and re-scheduled.

A further COVID-19 onsite screen will occur on arrival at the practice, where your temperature will be taken to accurately measure the presence of fever, and some screening questions may be asked.

All personal information will be stored securely and privacy maintained at all times.

Thank you for your patience and kind understanding as the practice is doing its utmost to ensure that it is a COVID-Safe business.

Name (First and Last Name) *

Name(s) of anyone in your care or accompanying you to the practice (Type N/A if irrelevant) *

Mobile Phone *

Email *

Date that you are attending your appointment at the practice *

YYYY

Please answer the following questions: *

Yes

Do you, or anyone in your care/household, have any of the following symptoms (even if mild), such as a cough, sore throat, runny nose, shortness of breath, chills, body aches, loss of smell, and/or fever? (Check symptoms at https://www.health.gov.au/resources/apps-and-tools/healthdirect-coronavirus-covid-19-symptom-checker)

Have you, or anyone in your care/household, been in contact with someone who has been unwell?

Have you, or anyone in your care, been instructed to self-isolate?

Have you, or anyone in your care/household, been in contact with someone who has tested positive for COVID-19 in the last 14 days?

Have you, or anyone in your care/household, returned from overseas in the last 14 days?

Have you, or anyone in your care/household, been in contact with someone who has returned from overseas in the last 14 days?

Have you, or anyone in your care/household, been to any Sydney, New South Wales or other Australian hotspot locations in the last 14 days? (Check locations at https://bit.ly/COVID19augovhealthalert)

Have you, or anyone in your care/household, been in contact with someone who has been to any Sydney, New South Wales, or other Australian hotspot locations in the last 14 days? (Check locations at https://bit.ly/COVID19augovhealthalert)

Yes

Have you, or anyone in your care/household, been in contact with someone who has been unwell?

Have you, or anyone in your care, been instructed to self-isolate?

Have you, or anyone in your care/household, been in contact with someone who has tested positive for COVID-19 in the last 14 days?

Have you, or anyone in your care/household, returned from overseas in the last 14 days?

Have you, or anyone in your care/household, been in contact with someone who has returned from overseas in the last 14 days?

Have you, or anyone in your care/household, been to any Sydney, New South Wales or other Australian hotspot locations in the last 14 days? (Check locations at https://bit.ly/COVID19augovhealthalert)

If you have answered 'Yes' to any of the questions, please:

1. DO NOT attend your appointment at the practice.
2. Stay home and self-isolate.
3. Contact the practice to reschedule your face-to-face appointment to a telehealth appointment.
4. Get tested as soon as possible; find the nearest COVID-19 testing clinic by contacting 1800 020 080 or visiting https://www.nsw.gov.au/covid-19/how-to-protect-yourself-and-others/clinics#covidtestingclinic.
5. Consult with your General Practitioner.
6. Call Healthdirect on 1800 020 080 for any questions or concerns about COVID-19 or any other health issues.

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