Covid-19 Questionnaire | City Dentists Wellington

Do you have a confirmed diagnosis of COVID-19? *

Yes
No

Are you a probable COVID-19 case? *

Yes
No

Are you required to self-isolate and/or waiting for a COVID-19 test or the results? *

Yes
No

Have you had close contact with other people in the last 14 days who are probable or confirmed COVID-19 case? *

Yes
No

Have you travelled overseas in the last 14 days and been required to quarantine on your arrival to New Zealand? *

Yes
No

Have you, in the last 14 days, worked on an international aircraft or shipping vessel and have been asked to self-isolate? *

Yes
No

Have you exited from an MIQ facility in the last 14 days? *

Yes
No

Are you a recovered COVID-19 case? *

Yes
No

Have you in the last 14 days stayed in or travelled from an area with an evolving community outbreak (including in New Zealand and any other country/area with which New Zealand has QFT)? *

Yes
No

Do you have new or worsening respiratory symptoms including one of the following: Cough, Sore throat, Shortness of breath, Runny nose, Sneezing, Post-nasal drip, Loss of smell? (with or without fever) *

Yes
No

Do you have any of the less typical symptoms, such as: Fever only, Diarrhoea, Headache, Myalgia, Nausea/Vomiting, Confusion? (where there is no other likely diagnosis) *

Yes
No

Have you had direct contact with someone in the last 14 days who has recently travelled overseas and been required to quarantine on their arrival to New Zealand? *

Yes
No

The following staff are considered to have either travelled overseas or had direct contact with someone who has, who is required to quarantine: * border staff (international airport and maritime port) * quarantine and isolation facility staff * international air crew and shipping vessel crew, except those who have travelled exclusively in the last 14 days between New Zealand and destinations with which New Zealand has QFT.

Have you cleaned at an international airport or maritime port in areas/conveniences visited by international arrivals in the last 14 days? *

Yes
No

Were these areas used by travellers from countries/areas with which New Zealand has QFT (Quarantine Free Travel)? *

Yes
No

Have you worked in cold storage areas of facilities that receive imported chilled/frozen goods directly from an international airport or maritime port in the last 14 days? *

Yes
No

I am *

a New Patient
an Existing Patient

Name *

First

Last

Mobile Phone Number *