Risk Assessment Form

Please tell us about your current health

We ask you for information about your current health to help us treat you safely. Please fill out your details below and answer the health questions. All information will be kept strictly confidential by the people caring for you.

Patient Details

(This needs to match the exact details you provided when you registered with us)

Current Health Details

Do you or any member of the household have any of these symptoms: a high temperature or a new continuous cough?

Any other uncommon symptom of fever, sore throat, cold, runny nose, diarrhoea, stomach issues, headaches, aches and pains, shortness of breath sneezing, loss of taste, loss of smell or fatigue?

Did you or any member of the household return from abroad in the last month?

Have you or any member of the household been in contact with a person tested positive for COVID?

Have you had any medical treatment recently?

Are there any changes in your medical status since the last time that you visited us?

Please type your name in BLOCK CAPITALS