Inspection
Personal Health & Hygiene
Do you have any flu symptoms such as headaches, running nose, sore throat, cough or fever?
Has anyone in your home travelled overseas in the past two weeks?
Do you have hand sanitizer and hand soap on hand?
Have you been in contact with anyone currently carrying COVI-19
Is anyone else in your household self isolating?
Have you been in contact with anyone currently self isolating?
Underlying Conditions
Are you 70 or over?
Do you suffer from any of the following?
- Recent organ transplant
- Cancer and undergoing cancer treatment
- Cancer of the blood or bone marrow
- Severe asthma
- Cystic Fibrosis
- Severe kidney disease (on dialysis)
- None
If any of the above is selected, then person should self isolate.
Are you pregnant?
Do you suffer from any of the following?
- Asthma
- COPD
- Emphysema
- Bronchitis
- Chronic Heart disease / Heart Failure
- Chronic Kidney disease
- Chronic Liver disease
- Parkinsons Disease
- Motor neurone disease
- MS
- Cerebral Palsy
- Diabetes
- Sickle cell disease
- Removed Spleen
- Weakened immune system from HIV or AIDS
- Weakened immune system from steroids
- Weakened immune system from Chemotherapy
- Overweight (BMI of over 40)
- Other
- None
Please write in here any other condition that may be relevant?
If any of the above have been selected, then social distancing is recommended
Sign off
Advised to
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