Remote Risk Assessment & Triage Form

Name *

First Name

Last Name

Level of pain *

Please indicate the level of pain you're currently in

No pain

Mild

Moderate

Severe

Very Severe

COVID-19 TRIAGE QUESTIONS

Please tick if you have experienced any of these symptoms or any that apply. These questions are required due to the ongoing COVID-19 pandemic.

Have you had a high temperature; above 37.8c in the past 2 weeks?

Have you had the Corona Virus?

Are you experiencing any shortness of breath/chest pain/tightness?

Have you had a test for COVID-19?

Was this test negative?

Was this test positive?

Do you have or have you had recent cold/flu-like symptoms, ie cough, sore throat, headache, body aches, drowsiness?

Do you have any unusual abdominal symptoms - loss of appetite, diarrhoea?

Do you have a loss of smell or taste?

Have you had exposure to a suspected or confirmed case of COVID-19? (eg someone in your household or co-worker)

Are you living with someone that is self-isolating due to symptoms of COVID-19?

Have you travelled off island in the last 14 days?

Are you living with someone who has travelled off island in the last 14 days?

Have you had laboratory exposure working directly with biological specimens that contain COVID-19?

Are you a health-care worker or first responder? (including volunteer first responder)

Is anyone in your household poorly? *

Yes

No

Are you currently pregnant? *

Yes

No

Are you over 70 years of age? *

Yes

No

Do you have a long-term health condition or underlying medical conditions as listed in government guidelines?

If so, please tick all that apply.

Chronic respiratory diseases such as chronic asthma, chronic obstructive pulmonary disease, emphysema or bronchitis

Chronic heart disease, such as heart failure

Chronic kidney disease

Chronic liver disease such as hepatitis

Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, MS, learning disability or cerebral palsy

Diabetes

Problems with spleen, such as sickle cell disease or removal

A weakened immune system as the result of conditions such as HIV or AIDS, or medicines such steroid tablets or chemotherapy

Not seriously overweight with a body mass index of 40 or above

I do not have any long term health conditions

Upon arrival at the premises or room you will be required to have a temperature check with a non contact thermometer. *

I consent to this practice

I DO NOT consent to this practice

If you require a chaperone, the chaperone will have to go through the same COVID-19 triage process. *

I agree and consent to this practice

I DO NOT agree and do not consent to this practice

You do not have to wear any PPE unless you wish to. If PPE is being worn, we may have to ask you to remove it if it interferes with assessment or treatment. *

I agree

I do not agree