COVID-19 Patient Screening QuestionnaireNeil2021-01-12T04:38:13+00:00 To help us provide care to our patients in the midst of the COVID-19 pandemic, we are asking all patients to provide the following information prior to making an office appointment. It is essential that this information is accurate and complete. We respect your privacy and this information will be protected. Thank you for your cooperation. (UK HAIR TRANSPLANT CLINICS)Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Mobile Phone*Email* At any time in the past month, have you or any close contact experienced any of the following:Confirmed Coronavirus infection*NoYesClose ContactFever*NoYesClose ContactCough*NoYesClose ContactShortness of breath*NoYesClose ContactDiarrhoea*NoYesClose ContactLoss of sense of smell or taste*NoYesClose ContactBlisters, bumps or discolouration of the toes*NoYesClose ContactDetails*Have you and your close contacts been practicing social distancing and hand washing as recommended by the government for the past 30 days?NoYesClose ContactHave you travelled abroad in the past 7 days?*YesNoPlease list all travel abroad in the past 30 days*Have you been in contact with anyone in a high infection area?*YesNoPatient Declaration* I declare that the above statements are true, accurate and complete
