Covid19 COVID-19 PRE-APPOINTMENT SCREENING FORM Covid-19 Screening Kia Ora, Thank you for making an appointment with Auckland University Optometry Clinic Please complete the following declaration for both you and your support person before you attend your session in person. This information is held by UoA Clinics. We are performing screening questions to all our patients, participants and their families/caregivers/support personnel related to COVID-19. Patient first name(s) * Patient last name * Appointment time * Are you bringing a support person? * Yes No First name of support person * Last name of support person * In the last 48 hours do you or your support person have any of the following new or worsening symptoms? Please choose from the list below Fever or chills Cough Shortness of breath or difficulty in breathing Fatigue Muscle or body aches Headache Diarrhoea Sore throat Sneezing / runny nose / head cold / congestion Loss of smell / taste Nausea or vomiting None of the above In the last 10 days have you or your support person Had a positive Covid test Had a 'Household Contact' (as defined by MOH) with someone who has COVID-19? None of the above This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Submit
