Covid-19 Screening for face to face treatment
Patient Name
Patient Name
First
Last
Do you have a probable or confirmed diagnosis of COVID-19?
Have you been notified by MOH as a casual contact?
Are you or anyone else in your bubble required to self-isolate and/or waiting for a COVID-19 test results?
Do you have new or worsening respiratory symptoms, including one of the following: new or worsening cough, sneezing and runny nose, sore throat, fever, temporary loss of smell or altered sense of taste, shortness of breath?
Do you have any of the less common symptoms, such as diarrhoea, muscle aches, nausea, vomiting, malaise, chest pain, joint pain or confusion/irritability – where there is no other likely diagnosis?
In the last 14 days before the start of your symptoms have you:

Had close contact with someone who is a probable or confirmed COVID-19 case?
Been in attendance at a current location of interest?
Travelled internationally (excluding travel by air from a country/area with which has New Zealand quarantine-free travel (QFT))?
Had direct contact with someone who has travelled overseas (excluding travel by air from a QFT country area)? This includes border staff, quarantine and isolation facility staff, and international aircraft and shipping vessel crew, except those who have travelled exclusively between New Zealand and QFT destinations.
Exited an MIQ facility (excluding recovered COVID-19 cases)?
Worked on international aircraft or shipping vessel (excluding aircraft/vessels from a QFT country/area?)
Cleaned at an International airport or maritime port in areas/conveniences visited by international arrivals (excluding areas/conveniences for travellers by air from a QFT country/area)?
Worked in cold storage areas or facilities that receive imported chilled and frozen goods directly from an international or maritime port?
Travelled from an area with an evolving community outbreak (including New Zealand and any other country/area with which New Zealand has QFT)?
Are you willing to disclose your vaccination status? (Confirmation of full vaccination status is required for face-to-face appointments)
If yes are you fully vaccinated: