Patient Form

Medical History





NoYes


NoYes

NoYes

NoYes

NoYes

  • New continuous cough? (this means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If you usually have a cough, it may be worse than usual.
  • High temperature or fever?
  • Loss of, or change in, sense of smell
    or taste?

NoYes



NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

Social History



NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

CigarettesPanE-cigarettesGutkhaSupari

NoYes - ModerateYes - Excessive

Contact Details




TextEmail

Details of person to contact in an emergency