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:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please provide the date of your upcoming visit to Vitalab here:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are 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?*YesNoHave you had a sudden onset (within the last 24 hours) of cold or flu symptoms such as fever, cough, sore throat or difficulty breathing?*YesNoHave you or anyone in your household had any cold/flu like symptoms within the past 7 Days?*YesNoHave you or your household had any contact with any persons having cold/flu like symptoms within the past 7 Days?*YesNoDo you have or have had any illness in the past 14 Days?*YesNoHave you or anyone in your household been tested outside of Vitalab for COVID-19 in the past 7 days?*YesNoTerms & 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. This iframe contains the logic required to handle Ajax powered Gravity Forms.