Health Disclosure Form

To safeguard our community- your family, our staff, sub-contractors and suppliers and to assist in minimising the potential spread of the novel coronavirus (COVID-19) in the greater community, prior to you attending our office/display home/work site, please complete this simple screening questionnaire. This information will allow us to determine any precautionary measures required to protect all parties, based on the advice issued by the Australian Government Department of Health.

Question Title

* 1. Client Appointment Details

Name

Date

Address

Address 2

City/Town

State

Email Address

Phone Number

Question Title

* 2. My appointment is with

Question Title

* 3. My appointment is at

Question Title

* 4. When is your appointment scheduled

Date / Time

Date

Time

AM/PM

Question Title

* 5. In the last 14 days have you or someone in your home or someone you have regular close contact with (such as family, friends, housemates and co-workers etc) been displaying any of the following symptoms similar to the flu:

	Yes	No
Fever	Fever Yes	Fever No
Cough	Cough Yes	Cough No
Shortness of breath	Shortness of breath Yes	Shortness of breath No
Breathing difficulties	Breathing difficulties Yes	Breathing difficulties No

Question Title

* 6. In the last 14 days have you or someone in your home or someone you have regular close contact with (such as family, friends, housemates and co-workers etc) been:

	Yes	No
Exposed to a person who has tested positive to coronavirus?	Exposed to a person who has tested positive to coronavirus? Yes	Exposed to a person who has tested positive to coronavirus? No
Have had a test for Coronavirus without a negative outcome?	Have had a test for Coronavirus without a negative outcome? Yes	Have had a test for Coronavirus without a negative outcome? No
Returned from overseas?	Returned from overseas? Yes	Returned from overseas? No
Placed in quarantine?	Placed in quarantine? Yes	Placed in quarantine? No
Been in contact with a person in self isolation	Been in contact with a person in self isolation Yes	Been in contact with a person in self isolation No

If yes, to any of the above please be advised at this time we are unable to meet with you. We are happy to reschedule your appointment at a convenient time 14 days after all the answers are No.

Please be assured that our staff members are required to complete the same form and are to update us immediately if anything changes.

All interactions must adhere to social distancing protocols and increased hygiene measures as outlined on Australian Government Department of Health inclusive of no handshaking and keeping 1.5 metres from people.

As the situation is changing daily, please continue to check the Australian Government website for updates. We thank you for your assistance during