Dear Patient,

It is vitally important that we collect and regularly update this information about you. We know its not everyones favourite thing to do, but it ensures we give you the best care possible.

Please be as thorough and give as much information as possible.

The Save button at the bottom will allow you to save progress and return to complete the form later.

Due to additional precautions resulting from the COVID-19 pandemic, please submit this completed form 3 days before your appointment rather than 48 hours as previously requested.

This form data will be securely retained. We will send you a link to your existing data prior to each appointment.

You will only need to update any areas of the form that have changed when you next attend without having to complete the whole form again.

Thank you!

COVID-19 History

Please complete as thoroughly as possible.

COVID-19 section

COVID-19-specific questions - it is important that you respond to these questions fully for us to be able to risk-assess you for attendance

First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

IMPORTANT: Have you been in communication with someone who may have COVID-19 (coronavirus) infection or had any of the following recently? PLEASE TICK ALL THAT APPLY. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Coronavirus COVID-19 advice is available on the government website

IF YOU HAVE RESPONDED POSITIVELY TO ANY OF THESE SYMPTOMS WE WOULD STRONGLY ADVISE SELF-ISOLATING AND DELAYING NON-ESSENTIAL CARE FOR AT LEAST ONE MONTH. IF YOU HAVE A DENTAL EMERGENCY PLEASE CONTACT THE PRACTICE SO THAT WE MAY MAKE SPECIAL ARRANGEMENTS FOR YOUR EMERGENCY CARE.

Based on your activity over the last 4 weeks, how would you subjectively assess your risk of being exposed to or infected by COVID-19? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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If you have been previously infected, or suspect you may have been, please tick all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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If you have recovered from COVID-19, how were you confirmed negative? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Please give details, dates and locations of tests and forward all documentation to the practice upload link below this box. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please upload any documents such as testing appointments and laboratory results relating to your COVID-19 status here: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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{binding Description}

Please look at the two risk columns below: Are you in a HIGH or MODERATE Risk group below for COVID-19? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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People at high risk (clinically extremely vulnerable)

As defined by the NHS at https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/

People at high risk from coronavirus include people who:

have had an organ transplant
are having chemotherapy or antibody treatment for cancer, including immunotherapy
are having an intense course of radiotherapy (radical radiotherapy) for lung cancer
are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)
have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)
have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine
have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)
have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell)
are taking medicine that makes them much more likely to get infections (such as high doses of steroids or immunosuppressant medicine)
have a serious heart condition and are pregnant

If you're at high risk from coronavirus, you should have received a letter from the NHS.

Speak to your GP or hospital care team if you have not been contacted and think you should have been.

People at moderate risk (clinically vulnerable)

As defined by the NHS at https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/

People at moderate risk from coronavirus include people who:

are 70 or older
are pregnant
have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)
have heart disease (such as heart failure)
have diabetes
have chronic kidney disease
have liver disease (such as hepatitis)
have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)
have a condition that means they have a high risk of getting infections
are taking medicine that can affect the immune system (such as low doses of steroids)
are very obese (a BMI of 40 or above)

Dear Patient,

It is vitally important that we collect and regularly update this information about you. We know its not everyones favourite thing to do, but it ensures we give you the best care possible.

Please be as thorough and give as much information as possible.

The Save button at the bottom will allow you to save progress and return to complete the form later.

Due to additional precautions resulting from the COVID-19 pandemic, please submit this completed form 3 days before your appointment rather than 48 hours as previously requested.

This form data will be securely retained. We will send you a link to your existing data prior to each appointment.

You will only need to update any areas of the form that have changed when you next attend without having to complete the whole form again.

Thank you!

COVID-19 History

Please complete as thoroughly as possible.

COVID-19 section

First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have been previously infected, or suspect you may have been, please tick all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have recovered from COVID-19, how were you confirmed negative? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please upload any documents such as testing appointments and laboratory results relating to your COVID-19 status here: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Please look at the two risk columns below: Are you in a HIGH or MODERATE Risk group below for COVID-19? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

People at high risk (clinically extremely vulnerable)

As defined by the NHS at https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/

People at high risk from coronavirus include people who:

have had an organ transplant
are having chemotherapy or antibody treatment for cancer, including immunotherapy
are having an intense course of radiotherapy (radical radiotherapy) for lung cancer
are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)
have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)
have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine
have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)
have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell)
are taking medicine that makes them much more likely to get infections (such as high doses of steroids or immunosuppressant medicine)
have a serious heart condition and are pregnant

If you're at high risk from coronavirus, you should have received a letter from the NHS.

Speak to your GP or hospital care team if you have not been contacted and think you should have been.

People at moderate risk (clinically vulnerable)

As defined by the NHS at https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/

People at moderate risk from coronavirus include people who:

are 70 or older
are pregnant
have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)
have heart disease (such as heart failure)
have diabetes
have chronic kidney disease
have liver disease (such as hepatitis)
have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)
have a condition that means they have a high risk of getting infections
are taking medicine that can affect the immune system (such as low doses of steroids)
are very obese (a BMI of 40 or above)

The email has been sent.

Your progress has been saved.

Copy your form link:

Email me my link:

{ binding firstError.message }

Dear Patient,

It is vitally important that we collect and regularly update this information about you. We know its not everyones favourite thing to do, but it ensures we give you the best care possible.

Please be as thorough and give as much information as possible.

The Save button at the bottom will allow you to save progress and return to complete the form later.

Due to additional precautions resulting from the COVID-19 pandemic, please submit this completed form 3 days before your appointment rather than 48 hours as previously requested.

This form data will be securely retained. We will send you a link to your existing data prior to each appointment.

You will only need to update any areas of the form that have changed when you next attend without having to complete the whole form again.

Thank you!

COVID-19 History

Please complete as thoroughly as possible.

COVID-19 section

First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have been previously infected, or suspect you may have been, please tick all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have recovered from COVID-19, how were you confirmed negative? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please upload any documents such as testing appointments and laboratory results relating to your COVID-19 status here: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Please look at the two risk columns below: Are you in a HIGH or MODERATE Risk group below for COVID-19? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

People at high risk (clinically extremely vulnerable)

As defined by the NHS at https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/

People at high risk from coronavirus include people who:

have had an organ transplant
are having chemotherapy or antibody treatment for cancer, including immunotherapy
are having an intense course of radiotherapy (radical radiotherapy) for lung cancer
are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)
have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)
have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine
have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)
have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell)
are taking medicine that makes them much more likely to get infections (such as high doses of steroids or immunosuppressant medicine)
have a serious heart condition and are pregnant

If you're at high risk from coronavirus, you should have received a letter from the NHS.

Speak to your GP or hospital care team if you have not been contacted and think you should have been.

People at moderate risk (clinically vulnerable)

As defined by the NHS at https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/

People at moderate risk from coronavirus include people who:

are 70 or older
are pregnant
have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)
have heart disease (such as heart failure)
have diabetes
have chronic kidney disease
have liver disease (such as hepatitis)
have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)
have a condition that means they have a high risk of getting infections
are taking medicine that can affect the immune system (such as low doses of steroids)
are very obese (a BMI of 40 or above)