Name * Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Increased risk of serious COVID-19 complications Do you have any underlying health issues such as heart, lung or kidney disease, diabetes or auto-immune disorders? * Yes No Are you or anyone in your household currently ‘’shielding’’? * Yes No Risk of current COVID-19 infection – in the last 14 days Have you felt feverish or had a temperature of 37.8°C or higher? * Yes No Do you have a new, persistent cough? * Yes No Are you having shortness of breath or any difficulties breathing? * Yes No Any flu-like symptoms such as stomach upset, fatigue or unusual tiredness, muscle pains or a persistent headache? * Yes No Have you experienced recent loss of taste, smell or appetite? * Yes No Has anyone you live or work with had any of the symptoms above? * Yes No If you or anyone in your household has tested positive for coronavirus, are you still in the self/household isolation period? * Yes No Signature Signer Name * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.