COVID-19 Questionnaire COVID-19 Questionnaire For your safety as well as that of the community, the following question group is designed to assess your risk regarding COVID-19. Please note that COVID-19 is the specific name of the current coronavirus pandemic, due to the existence of multiple forms of coronavirus, the following question set will refer to it as COVID-19Have you completed an Enriched Health Care COVID-19 questionnaire in the last 7 days?* Yes No Is the information you provided still accurate?* Yes No Are you currently checking in to the Enriched Health Care Clinic?* Yes No I acknowledge that I must sign in to Enriched Health Care's visitor sign in systems* Yes No HiddenMy temperature was below 37.5 degrees celsius for this check in to Enriched Health Care Full Name:* Phone* Date* DD slash MM slash YYYY Date of Birth:* DD slash MM slash YYYY dd/mm/yyyyCan you please confirm if you are of the following: Patient/Participant/Carer/Family Member/Support Worker Business customer Supplier Team Member Approved Agile Provider COVID-19 Social Distancing & Hygiene Please confirm that you are practising the following social distancing rules. HiddenI am: Maintaining a minimum distance of 1.5 metres from people, when in public Practising good hygiene and washing my hands regularly Coughing and sneezing in my elbow or a tissue that is disposed of appropriately Avoiding handshakes and other contact greetings Regularly cleaning surfaces that are touched including bench tops, door handles etc Limiting travel and outings as directed by government and health authorities HiddenAre you using the Service NSW app (or alternative check in method) to complete a Covid Safe Check-in for all premises you attend? Yes No HiddenDoes your Service NSW COVID Safe Check-in History display any COVID-19 case alerts for premises you have attended in the past 28 days? If yes, we ask you to refrain from visiting Enriched Health Care for 15 days, from the date of the most recent COVID-19 case alert. Yes No HiddenIf your Service NSW COVID Safe Check-in history displays any COVID-19 case alerts, please list details of all COVID-19 case alerts HiddenIf you have used an alternate method to check in to premises (other than the Service NSW COVID Safe Check-in), have you been contacted to confirm a COVID-19 case alert applies to you? If yes, we ask you to refrain from visiting Enriched Health Care for 15 days, from the date of the most recent COVID-19 case alert. Yes No HiddenIf you have been contacted to confirm a COVID-19 case alert applies to you, please list details of all COVID-19 case alerts What is your current COVID-19 vaccination status?* Fully vaccinated – have received three (3) doses of a COVID-19 vaccine Vaccinated – have received two (2) doses of a COVID-19 vaccine Partially vaccinated – have received one (1) dose of a COVID-19 vaccine Unvaccinated Please note: you may be asked to produce your COVID-19 vaccination evidenceDo you have access to face masks and are you able to wear a face mask for your appointment with Enriched Health Care? Please note: face masks are required for attendance to all Enriched Health Care appointments. Please liaise with Enriched Health Care if you do not have access to face masks or if you are unable to wear a face mask.* Yes No All people over the age of 12 are required to wear a face mask. If you are unable to wear a face mask because of a disability, physical illness, or mental health condition, please include details below. You will also be required to provide proof of a medical exemption.* Over the last 15 days, have you had any of the following symptoms: fever (37.5 ° or higher), cough, sore throat, shortness of breath (difficulty breathing), runny nose, loss of taste, loss of smell, fatigue, acute blocked nosed (congestion), muscle pain, joint pain, headache, diarrhoea, nausea/vomiting, loss of appetite? If yes, we ask you to get a COVID-19 test and refrain from visiting Enriched Health Care until you receive COVID-19 negative results from your test and have had no symptoms for at least 72 hours* Yes No Please select symptoms which you have had:* Fever (37.5 degrees or higher) Cough Sore Throat Shortness of breath or difficulty breathing Runny nose Loss of smell or loss of taste Fatigue Acute blocked nose (congestion) Muscle Pain Joint Pain Headache Diarrhoea Nausea or vomiting Loss of appetite Have you completed a COVID-19 test?* Yes No What type of COVID-19 test did you complete?* Rapid Antigen test (RAT) Polymerase Chain Reaction test (PCR) What date did you complete a COVID-19 test?* DD slash MM slash YYYY What were your COVID-19 test results?* Negative Positive Results are pending (not confirmed) Please provide an image of these COVID-19 test results*Max. file size: 20 MB.Have you had any of these symptoms in the last 72 hours? If yes, we ask you to refrain from visiting Enriched Health Care until you have had zero symptoms for at least 72 hours* Yes No Over the last 15 days, have you been in contact with anyone who's had any of the following symptoms: fever (37.5 ° or higher), cough, sore throat, shortness of breath (difficulty breathing), runny nose, loss of taste, loss of smell, fatigue, acute blocked nosed (congestion), muscle pain, joint pain, headache, diarrhoea, nausea/vomiting, loss of appetite? If yes, we ask you to get a COVID-19 test and refrain from visiting Enriched Health Care until you receive COVID-19 negative results from your test and have had no symptoms for at least 72 hours* Yes No Please select symptoms the person had:* Fever (37.5 degrees or higher) Cough Sore Throat Shortness of breath or difficulty breathing Runny nose Loss of smell or loss of taste Fatigue Acute blocked nose (congestion) Muscle Pain Joint Pain Headache Diarrhoea Nausea or vomiting Loss of appetite Has the person completed a COVID-19 test?* Yes No What type of COVID-19 test did the person complete?* Rapid Antigen test (RAT) Polymerase Chain Reaction test (PCR) What date did the person complete a COVID-19 test?* MM slash DD slash YYYY What were the person's COVID-19 test results?* Negative Positive Results are pending (not confirmed) HiddenHas the person had any of these symptoms in the last 72 hours? If yes, we ask you to refrain from visiting Enriched Health Care until you have had zero symptoms for at least 72 hours Yes No Have you, or any of your family members or household members been in contact with a suspected or confirmed case of COVID-19? If yes, we ask you to refrain from visiting Enriched Health Care for 15 days, from the date of last contact with the person confirmed or suspected to have COVID-19.* Yes No Is anyone in your household currently self-isolating? If yes, we ask you to refrain from visiting Enriched Health Care for 15 days, from the date of last contact with the person who is self-isolating.* Yes No HiddenHave you, your household members, or anyone you've been in close contact with, travelled internationally in the past 30 days? If yes, please refrain from visiting Enriched Health Care for 15 days* Yes No HiddenPlease list any countries you, or the person you've been in contact with has visited or passed through in the last 30 days*HiddenWhat date did you, your household member or the person you've been in close contact with return to your current location?* HiddenDid the person who travelled internationally complete an isolation period before you were in contact with them?* Yes No HiddenHave you visited any other state, territory or region in the last 15 days? Yes No HiddenPlease list any other state, territory or region you have visited in the last 15 daysHave you been in contact with anyone you know has tested positive to COVID-19 or who is currently undergoing testing to determine if they have COVID-19? This includes but is not limited to household members.* Yes No What date did the person complete a COVID-19 test?* DD slash MM slash YYYY dd/mm/yyyyWhat were the results of the person's COVID-19 test?* Negative Positive Results are pending (not confirmed) What date did the person receive the COVID-19 results?* DD slash MM slash YYYY dd/mm/yyyyHave you been submitted to testing to determine if you have COVID-19?* Yes No What date were you submitted to COVID-19 testing?* DD slash MM slash YYYY dd/mm/yyyyWhat were the results of your COVID-19 test?* Negative Positive Results are pending (not confirmed) What date did you receive the COVID-19 results?* DD slash MM slash YYYY dd/mm/yyyyPlease provide an image of these COVID-19 test results*Max. file size: 20 MB.HiddenWere you hospitalised for treatment of COVID-19? Yes No Have you been in self-isolation during the last 30 days due to any of the following reasons – illness, having COVID-19 symptoms, testing positive to COVID-19, exposure to someone who had COVID-19 symptoms or tested positive to COVID-19, receiving a COVID-19 case alert for your COVID Safe Check-in History, travelled internationally or been in close contact with someone who travelled internationally? (Do not select yes for self-isolation due to government mandated population isolation)** Yes No What was the reason you completed self-isolation?* How many days did you self-isolate for?* Are you still in self-isolation?* Yes No Have you received a medical clearance notice from an authorised Medical Practitioner or Registered Nurse?* Yes No HiddenDo you have access and are you able to wear them for your appointment with Enriched Health Care? Please note: face masks are required for attendance to all Enriched Health Care appointments. Please liaise with Enriched Health Care if you do not have access to face masks or if you are unable to wear a face mask. Yes No HiddenDo you have access to hand sanitiser? Yes No I confirm that the information provided above is correct and that if any circumstances are to change, I will inform the Enriched Health Care team.* Yes CONSENT & DECLARATION I acknowledge and agree that the information provided by me in this form and any other information that I may subsequently provide may be disclosed to: Any entity involved in any restructure or transfer of Enriched Heath Care; Enriched Pty Ltd and any related bodies corporate of Enriched Heath Care; or Employees, agents, government agencies or contractors or other service providers of Enriched Heath Care who reasonably require access to the information upon which I have signed a medical authority to release By Signing below, you consent for Enriched Health Care to share medical or other information with other contacts and health care providers where relevant Signature* Δ
