Online COVID19 Screening QuestionnaireDear Patient, this online questionnaire needs to be completed before EVERY visit to the Clinic. Should anyone accompany you to the visit, please ensure they also complete one of these questionnaires. To prevent overcrowding and to adhere to social distancing policies, Vitalab’s Reception / Staff Member may request that your partner or person accompanying you must wait in the CAR. All temperatures will be taken upon arrival at Vitalab. Please provide your File Number here:*Please provide your Email address here:*Please provide your Date of Birth here:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please provide the date of your upcoming visit to Vitalab here:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you or anyone in your household a healthcare worker?*YesNoDo you or anyone in your household work in a healthcare facility where patients are being treated for COVID-19?*YesNoIn the past 14 Days, have you or anyone in your household attended a medical facility (specifically a Hospital, Clinic or Doctors Office) other than Vitalab?*YesNoIf "Yes", which Facility?Have you had a sudden onset (within the last 24 hours) of cold or flu symptoms such as fever, cough, sore throat or difficulty breathing?*YesNoIf "Yes", describe the SymptomsHave you or your household had flu like symptoms or been in contact with any persons having flu like symptoms within the past 7 days?*YesNoIf "Yes", describe with whom and their symptomsHave you had any illness in the past 14 days?*YesNoIf "Yes", describe what illnessHave you or anyone in your household been tested for COVID-19 in the past 14 days not requested by your Vitalab Doctor?*YesNoIf "Yes", provide the result and the laboratory that ran the testHow did you hear about Vitalab*How did you hear about VitalabGoogleFacebookTwitterLinkedInFamily or FriendEventNewspaperSASREGTerms & Conditions:Please read and accept our T&Cs before submitting your online Questionnaire. Should you have any questions, concerns or comments please either phone 011 911 4700, or email firstname.lastname@example.org for further assistance but please be patient with them during this time. * I have answered all the questionnaire questions truthfully and to the best of my ability, at the time of submitting this form.* I am aware that I must wear a MASK throughout my entire visit at Vitalab, if I do not own one then one can be purchased from the Pharmacy at Vitalab.* I am aware that I am NOT allowed to wear gloves for my visit at Vitalab.* I will keep to all sanitising, social distancing and other COVID-19 protocols which are implemented at Vitalab on the day of my visit.* I am aware that my partner or accompanying person may be requested to wait in the CAR.* I am aware that due to COVID-19 protocols unfortunately no children are allowed entry to the Clinic.CAPTCHANameThis field is for validation purposes and should be left unchanged.