Medical History Form

Complete Your

Medical History Form

    Which category below would you put yourself into for exposure to Covid 19 in the last

    High risk - Frontline health worker or carer or confirmed case of Covid 19 in your own householdModerate risk - Keyworker in contact with the public, but have had no symptoms or exposure to someone who has been infected.Low risk - Have been isolating alone or with household and with minimum public contact. No known Covid 19 exposure.Have had Covid 19 and recovered, and this was confirmed by testing and documentationHave an underlying Health condition that puts you in a Vulnerable category

    YesNo - Has anyone in your household tested positive for Covid 19?
    YesNo - Is anyone isolating your household?

    Have you or anyone in your household experienced any of these symptoms in the last 3 weeks:

    YesNo - Shortness of breath or difficulty in breathing, that is new or different than before
    YesNo - New and persistent cough
    YesNo - Temperature over 37.8 celsius/100 fahrenheit or a Fever
    YesNo - Unexplained tiredness/lethargy
    YesNo - Loss of taste or smell
    YesNo - Muscles aching, that is new to you
    YesNo - Stomach upset problems that are new to you
    YesNo - Are you over 70 years old?

    YesNo - Are you currently receiving treatment from a doctor, hospital or clinic?
    YesNo - Do you carry a Medical warning card?
    YesNo - Are you diabetic (or is anyone in your family)?
    YesNo - Do you suffer from any allergies to medicines (e.g. penicillin), food or substances (e.g. latex/rubber)?
    YesNo - Do you suffer from Hayfever/Eczema?
    YesNo - Do you suffer from Bronchitis, asthma or other chest conditions?
    YesNo - Do you suffer from fainting attacks, giddiness, blackouts or Epilepsy?
    YesNo - Do you suffer from Heart problems, Angina, blood pressure problems or Stroke?
    YesNo - Do you suffer from Arthritis?
    YesNo - Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?
    YesNo - Do you suffer from any infectious diseases (including HIV and Hepatitis)
    YesNo - Have you ever had Rheumatic fever or Chorea?
    YesNo - Have you ever had Liver disease (e.g. jaundice,hepatitis) or kidney disease?
    YesNo - Have you ever had blood refused by the Blood transfusion service?
    YesNo - Have you ever had a bad reaction to a general or local anaesthetic?
    YesNo - Have you ever had joint replacement or other implant?
    YesNo - Have you ever had treatment that required you to be in hospital?
    YesNo - Do you have any close relatives with Creutzfeldt Jacob disease (mad cow disease)?
    YesNo - Have you ever had Heart surgery?
    YesNo - Have you ever had Brain surgery?
    YesNo - Have you anxiety, depression or any other social or mental health condition?

    YesNo - Do you Vape with an E-Cig?

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