Symptomatic COVID-19 Testing Form for Johnstown Family Practice

Due to the increased volume of phone and email queries about Coronavirus testing in light of broadening of testing criteria announced by the HSE - we are now asking symptomatic patients to fill out the following questionnaire to help us assess you more efficiently.

We understand our patients are concerned for themselves and their loved ones and we can assure you we are doing everything we can to operate as normally as possible in these extraordinary times, while at the same time minimising the risk of exposure to our patients or indeed our practice.

Please fill out the below form to help us triage your symptoms to see if you need testing for Covid-19*

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Please outline your symptoms below:
When did you start displaying symptoms?
How severe are your symptoms?
Anybody with respiratory symptoms of any kind is now advised to self-isolate.
Have you been in close contact with a confirmed coronavirus case?
Are you an existing patient of this practice or are you a new patient
Are you a healthcare worker with patient-facing contact?
History of ischaemic heart disease, high blood pressure, history of Stroke/TIA, Type II diabetes, obesity, active malignancy in last 5 years, chronic lung disease, chronic renal disease, chronic liver disease.
Please give a brief outline of your symptoms, when they started and your concern re testing. If you have any other symptoms not covered in the checklist above, please let us know here also.

By submitting this form, I consent to my data being stored, analysed and transferred to this GP practice for screening. I agree to the website privacy policy and I also agree to take responsibility to follow up with up GP practice directly if I have not heard back from them within 48 hours. You'll receive an email with your details shortly.