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* DD slash MM slash YYYY Mobile Phone*Email* At any time in the past 7 days, have you or any close contact experienced any of the following:Confirmed Coronavirus infection* No Yes Close Contact Fever* No Yes Close Contact Cough* No Yes Close Contact Shortness of breath* No Yes Close Contact Diarrhoea* No Yes Close Contact Loss of sense of smell or taste* No Yes Close Contact Blisters, bumps or discolouration of the toes* No Yes Close Contact Details*HiddenHave you and your close contacts been practicing social distancing and hand washing as recommended by the government for the past 30 days? No Yes Close Contact Have you travelled abroad in the past 7 days?* Yes No Please list all travel abroad in the past 7 days*Have you been in contact with anyone in a high infection area?* Yes No Patient Declaration* I declare that the above statements are true, accurate and complete
