COVID-19 Health Screening Questionnaire V5-0 WEF 1 Aug 2020
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Personal information (36236)
Have you recently returned from abroad, or are living in a designated local lockdown area (
https://www.gov.uk/government/collections/local-restrictions-areas-with-an-outbreak-of-coronavirus-covid-19
)
and are required to quarantine, or follow stricter guidelines, in
accordance with the latest Government guidance?
Personnel from these areas cannot attend ACs, Res BT, or UOTC trg that involves an overnight stay.
(443530)
Type: (L/list-radio)
NO
A2
First Name
(443489)
Type: (S/text-short)
Ross
Last Name
(443490)
Type: (S/text-short)
Mckenzie
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ID No (MOD No or Civilian ID)
(443491)
Type: (S/text-short)
553447792
Rank
(443492)
Type: (L/list-radio)
Other
A19
Which part of the United Kingdom are you in whilst you are completing this form?
(443522)
Type: (L/list-radio)
Scotland
A3
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Which County in Scotland are you in whilst you are completing this form?
(443524)
Type: (!/list-dropdown)
A19 - Midlothian
Please insert the Postcode, or location, you are physically in whilst completing this form.
(443526)
Type: (S/text-short)
EH8 8HX
What Operational Group are you joining for training/course/attachment/work? (443513)
Type: (L/list-radio)
RMAS Group
A3
Which part of the RMAS Group are you from?
(443517)
Type: (L/list-radio)
UOTC
A5
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Which UOTC are you serving in?
(443520)
Type: (L/list-radio)
Edinburgh
A6
Are you Regular, Reserve or Civilian?
(443494)
Type: (L/list-radio)
Civilian
A3
E-Mail
(443495)
Type: (S/text-short)
rossam98@gmail.com
Contact Telephone Number
(443496)
Type: (S/text-short)
07504634890
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I consent to the use of the information requested below to be used by my unit to determine safe return to the COVID-19 training environment; supplementary occupational health advice may be sought in some instances to support safe
assessment. I understand the importance of providing full and accurate responses to enable safe occupational decisions. I also consent to the temporary retention of the information by my unit
before the results of the questionnaire
may be passed to the Medical Centre for further action.
General Data Protection Act 2018 principles will apply throughout.
(443497)
Type: (L/list-radio)
YES
A1
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Occupational Health Questions (36237)
People with any of the following conditions are most vulnerable to COVID-19 infection.
If you have any of the conditions listed please answer YES.
You have received an organ transplant
You have had your spleen removed
You have cancer of the blood or bone marrow
You have any cancer and are receiving one of the following treatments;
active chemotherapy
radical radiotherapy
immunotherapy or antibody treatment
You have received a bone marrow or stem cell transplant in the past 6 months,
or with ongoing immunosuppression treatment
You have any
COPD, cystic fibrosis)
severe
respiratory (breathing) condition (including asthma,
You have a BMI of 40 or higher (seriously overweight)
You are pregnant
You have a condition that increases your susceptibility to infection
You have received a letter from your health care provider advising you to
shield
COVID additional 'risk conditions (list 1)
(443499)
Type: (L/list-radio)
NO
A2
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Some people with the following conditions may be at increased risk from COVID-19,
depending on their individual health circumstances.
If you have any of the conditions listed please answer YES.
Any respiratory (breathing) condition not mentioned in list 1 (ie not severe);
This includes asthma, COPD, emphysema, bronchitis, sarcoidosis,
obstructive sleep apnoea
You have had a pneumothorax in the past 6 months
Any heart condition;
This includes heart failure, cardiomyopathy, myocarditis, atrial
fibrillation
Diabetes
Receiving treatment for a thyroid condition
Receiving steroid replacement treatment
Any condition (including HIV) or medication (including steroid tablets such
as prednisolone) which could cause you to be immunosuppressed
Liver disease (including Hepatitis)
Kidney disease
Bowel disease
A neurological condition
You have multiple conditions
Any disease or injury of the spleen;
This includes reduced spleen function and sickle cell disease (but
You have been advised by your GP to have the annual flu vaccination for
not sickle cell trait)
medical reasons;
This does not include purely for work-related reasons
COVID additional 'risk' conditions (List 2)
(443500)
Type: (L/list-radio)
NO
A2
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Do you have any concerns about your health, in relation to COVID-19, that you would like to discuss with an Medical Centre (Medical Officer)/GP/Doctor?
(443501)
Type: (L/list-radio)
NO
A2
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COVID-19 Infection and contact (36238)
In the last 42 days (six weeks), have you had:
a new persistent cough (coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours)
a high temperature (37.8 C or higher, if available to measure)
or anosmia, (a loss of, or change in, your normal sense
, or feel feverish
of taste or smell)?
a positive test for COVID-19?
(443505)
Type: (L/list-radio)
NO
A2
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In the last fourteen days, has any member of your household had:
a new persistent cough (coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours)
a high temperature (37.8 C or higher, if available to measure)
, or feel feverish
or anosmia, (a loss of, or change in, your normal sense of taste or smell)?
a positive test for COVID-19?
(443506)
Type: (L/list-radio)
NO
A2
In the last ten days, have you had;
a new persistent cough (coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours)
a high temperature (37.8 C or higher, if available to measure)
or feel feverish,
or anosmia, (a loss of, or change in, your normal sense of taste or smell)?
a positive test for COVID-19?
(443504)
Type: (L/list-radio)
NO
A2
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Are you currently advised to self-isolate because you have had contact with someone with confirmed or suspected COVID-19, or tested positive for COVID-19?
(443507)
Type: (L/list-radio)
NO
A2
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