Visitor COVID-19 questionnaire WUMe Visitor COVID-19 questionnaire Which WUMe location will you be attending?*Please selectWUMe East MelbourneWUMe ToorongaWUMe Frances Perry HouseWUMe BaysideName* Title Mr.Mrs.MissMs.Dr.Prof.Rev. Surname Given names Date of Birth Patient's Name:Who is the Patient you are accompanying today First Last COVID-19Please respond to the questions below by ticking the boxes that apply to you and your visitor:Have you recently returned from Interstate or Overseas? Yes No To your knowledge, have you been in close or casual contact with someone who has subsequently been confirmed as having Corona Virus Disease 2019 – COVID-19 in the past 14 days? Yes No Have you experienced any of the following symptoms in the past 48 hours? Fever Chills and sweats Coughing Sore throat Shortness of breath Runny nose Loss of sense of smell Yes No Have you visited any of the Tier 1 or 2 exposure sites listed on the Victorian State Government’s DHHS website?View tier 1 and 2 exposure sites here. Yes No Are you currently awaiting the result of a COVID19 test? Yes No Visitor's Signature*Date CAPTCHA
