Transcription of COVID-19 Clinical Screening Assessment
1 2021 label here). URN: Family name: COVID-19 Given name(s): Clinical Screening Assessment Address: Facility: .. Date of birth: Sex: M F I. 1. Reason for Presentation: .. 2. In the last 14 days has the patient been in an area with an increased risk No of an exposure to people with covid Exposure venues or hotspots Yes (in the 14 days prior to illness onset). 3. When was the exposure? .. / .. / .. 4. Exposure location Contact with a confirmed COVID-19 case Overseas At a hotspot At an exposure venue An area of concern' Quarantine hotel COVID-19 Ward Other: .. 5. Is the patient subject to a quarantine order or public health order? No Yes 6. Is the patient a healthcare, aged or residential care worker involved with direct patient care? No Yes 7. Does the patient work/reside in any of the following high risk settings? None of the below DO NOT WRITE IN THIS BINDING MARGIN. Aged care and other residential care facilities Correctional and Detention facilities Do not reproduce by photocopying Remote industrial sites with accommodation ( mine sites).
2 Aboriginal and Torres Strait Islander rural and remote communities (in consultation with the local Public Health Unit). Food processing, distribution and cold storage facilities including abattoirs Quarantine hotel Crowded or high-density housing Homeless shelters and residential / crisis hostels 8. Has the patient received a covid Vaccination? 1 Dose 2 Doses None 9. What vaccine brand has been administered? Pfizer AstraZeneca Other: .. 10. Signs and Symptoms None Acute respiratory distress Anosmia (change/loss in smell) Arthralgia Cough Diarrhoea COVID-19 Clinical Screening Assessment . Dysgeusia (change/loss in taste) Fatigue Fever Headache Loss of appetite Muscle aches Nausea/Vomiting Rhinorrhoea Shortness of breath Sore throat Other: .. Symptom Onset Date: .. / .. / .. 11. Vital Signs: SpO2: .. Peripheral Pulse Rate: .. Respiratory Rate: .. Temperature: .. 12. Additional Information: .. - 07/2021.. 13. Outcome Advice only - no testing required based on guidelines at time of Screening Assessment Instructed to self-quarantine and present for testing if becomes symptomatic Tested - follow up required (patient instructed to self-isolate).
3 Refer for Direct Admission Refer to Emergency Department Refer to GP. Refer to QH Clinic Other: .. SW998. For further information on current guidelines visit Australian Government: The Department of Health website: Name: Designation: Signature: Date: Page 1 of 1.
