Covid-19 Safety Form Entry Log List Saved! Thank you. Start Again Home Medical Hisotry Form Name Are you double vaccinated? YES NO Wish not to disclose Have you been feeling unwell, YES NO Or have you had any of the following symptoms? Fever or temperature now or in the past 3 days? Sore throat, cough or shortness of breath? Runny/stuffy nose or other respiratory symptoms? Loss of smell or taste Others Have you, or person with whom you live, been asked to quarantine due to: YES Attending an area identified as high risk for community transmission. NO Interstate or international travel? If YES, when does your quarantine period end? / / Have you, or a person with whom you live, been asked to self-isolate white waiting for COVID-19 test results? YES NO Do you, or a person with whom you live, work, in a medi-hotel used for quarantine? YES NO Are you, or a person with whom you live, an essential worker who is travelling interstate? (e.g. freight, transport, removalists, aircrew). YES NO I declare my fill in details are genuine. Date: / / Reset Make changes Save Submit Note: After you fill in the form, please click Save and hand the tablet back to reception. If you are at home, after click submit then you can close your browser.