Respiratory Symptoms & Covid - Cantwell Spillane

Cantwell Spillane

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Respiratory Symptoms & Covid
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Homepage
Prescriptions
- Long-term Prescriptions
- Combined Oral Contraceptive Prescriptions
Respiratory Symptoms & Covid
UPLOADS

ONLY USE THIS FORM IF INSTRUCTED TO DO SO BY PRACTICE STAFF
SUBMISSIONS OUTSIDE OF WORKING HOURS WILL NOT BE REVIEWED

RESPIRATORY SYMPTOMS AND COVID TESTING FORM

* Indicates required field

Name and Date of Birth *

Address and Contact number *

PPS NUMBER *

Are you vaccinated against Covid 19 *

DATE SYMPTOMS STARTED *

Have you alraady had covid and if so what dates *

HOW MANY DAYS HAVE YOU HAD SYMPTOMS *

HOW MANY ANTIGENS HAVE YOU DONE FOR THIS ILLNESS *

DATES OF ANTIGENS *

WHEN DID YOU CONTACT THE SURGERY *

HAVE YOU BEEN TOLD TO CONTACT TLCDOC OR HAVE YOU ALREADY CONSULTED TLC DOC INCLUDE DATE *

COUGH *

YES NO

HIGH TEMP *

YES NO

SINUS SYMPTOMS *

YES NO

SORE THROAT *

YES NO

HEADACHE *

YES NO

HEAD COLD SYMPTOMS *

YES NO

LOSS OF TASTE OR SMELL *

YES NO

FATIGUE AND TIREDNESS *

YES NO

SHORT OF BREATH HARD TO BREATH *

YES NO

CONTACT WITH KNOWN COVID CASES CHOOSE ONE *

YES DEFINITELY NO DEFINITELY NOT PROBABLY

HAVE YOU UNDERLYING CONDITIONS *

IN THE EVENT YOU ARE TO GET A PCR TEST HOW WOULD YOU GET TO THE TEST CENTRE *

I CAN MAKE MY OWN WAY I NEED THE HSE TO CONTACT ME ABOUT ARRANGING A TEST I AM HOUSEBOUND WILL NEED A HOME TEST

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133 St Peter's Rd, Walkinstown, D12XN9F
Ph switch 4504168 Fax 4783175

23 Old Bawn Way, Tallaght, D24 TKP0
Ph switch 4504168

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