Covid19 Contact Tracing Patient Name * First Name Last Name Date of Birth * MM DD YYYY Mobile Phone * (###) ### #### Email * Name of Parent/Carer First Name Last Name Parent/Carer Contact Number (###) ### #### Date of appointment with Dr Rudolph * MM DD YYYY In the last 10 days, have you been tested for coronavirus (COVID-19)? * Yes No Pending Results Have you ever been diagnosed with coronavirus (COVID-19)? * Yes No If Yes Date diagnosed positive MM DD YYYY Have you been to an exposure site or interstate black/red/orange zone in the past 14 days? * Yes No Primary contact: Have you had contact with a person who has coronavirus (COVID-19) infection, has respiratory symptoms or is awaiting a test result in the past 14 days? * Yes No Secondary Contact: Have you had contact with someone: * • Who has been identified as a close contact of someone with coronavirus (COVID-19) or who has been to an exposure site or interstate black/red/orange zone in the past 14 days? • Who has been symptomatic with respiratory symptoms (undiagnosed)? • In the last month have you been contacted by DHHS or the contact tracing team and have been directed to isolate or quarantine for any reason? In the past 10 days have you had NEW onset of any of the following symptoms? • Fever or history of fever ≥ 37.5°C. e.g. or night sweats or chills? • A cough, sputum production? • A sore throat? • Shortness of breath, breathing difficulties, wheeze, pleuritic chest pain (pain when you breathe in)? • Other respiratory symptoms including stuffy/runny nose? • A recent loss of the sense of smell or taste? • Nausea, vomiting, diarrhoea, fatigue? Yes No Are you elderly (70 years plus) with an onset in the last 10 days of any of these atypical symptoms: Headache, myalgia (muscle aches), functional or cognitive decline, exacerbation of underlying chronic condition, falls, loss of appetite, malaise (feeling tired). * Yes No Vaccination Status: * Have you received a COVID-19 vaccination? Yes No If yes, which vaccination has been received? * AstraZeneca Pfizer Moderna Number of vaccinations: * 1 Dose 2 Doses Date of last vaccination: * MM DD YYYY I have read the information above and understand the reasons why this information must be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given. * I accept I do not accept Thank you!Please email your referral to: reception@visc.health
