PatientCarer accompanying patientProfessional VisitorDigestive Health Staff


    less than 15 minutes30 minutes1 hour3 hoursmore than 3 hours



    YesNo


    YesNo


    CloseCasualNo


    YesNo


    YesNo


    YesNo

    *CLOSE defined as: Spending > 15 minutes face to face OR sharing a closed space > two hours with a person who is a confirmed case 48 hours before they showed symptoms or once they showed symptoms.

    ** CASUAL defined as: Spending < 15 minutes face to face OR sharing a closed space < two hours with a person who is a confirmed case 48 hours AND had symptoms at the time.


    YesNo


    YesNo


    YesNo

    If yes what was the test date?:


    YesNo

    If Yes:

    Do you have any of the following symptoms Cough, Sore throat, Shortness of breath, Chills, Recent loss of sense of smell or taste, any other respiratory symptoms?

    YesNo

    If Yes, please list your symptoms here: