Visitor COVID-19 questionnaire WUMe Visitor COVID-19 questionnaireWhich 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 BirthPatient'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 NoTo 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 NoHave you experienced any of the following symptoms in the past 48 hours?FeverChills and sweatsCoughingSore throatShortness of breathRunny noseLoss of sense of smell Yes NoHave 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 NoAre you currently awaiting the result of a COVID19 test? Yes NoVisitor's Signature*DateCAPTCHA
