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Personal information:
Country:
*
State:
*
Suburb:
*
Age:
*
Height (Cm):
*
Weight (Kg):
*
Contact Number:
*
Confirm temperature:
Do you identify as indigenous / ATSI / TSI
*
Yes
No
age range
*
more than 45
less than 45
more than 60
Gender
*
Male
Female
Unknown
1. Have you returned from overseas or Interstate in the past 14 days and developed respiratory illness with or without fever?
*
Yes
No
2. Have you been in close contact with a confirmed COVID-19 case in the past 14 days and developed respiratory illness with or without fever?
*
Yes
No
3. Are you a healthcare worker who has direct patient contact?
*
Yes
No
4. Have you had an abnormal body aches and pains or headaches?
*
Yes
No
5. Have you had abnormal tiredness in recent days?
*
Yes
No
6. Have you had a runny nose recently?
*
Yes
No
7. Have you had abnormal fever or chills in recent days?
*
Yes
No
8. Have you had severe and frequent dry coughs in recent days?
*
Yes
No
9. Have you had a bad sore throat in recent days?
*
Yes
No
10. Have you experienced shortness of breath or difficulty in breathing (dyspnoea)?
*
Yes
No
11. Have you experienced persistent pain or pressure in your chest?
*
Yes
No
12. Have you experienced new confusion or drowsiness?
*
Yes
No
13. Have you experienced bluish lips or face?
*
Yes
No
14. Do you have any history of cardiovascular diseases?
*
Yes
No
15. Do you have asthma or other chronic respiratory diseases?
*
Yes
No
16. Do you have uncontrolled high blood pressure despite taking blood pressure medication?
*
Yes
No
17. Are you on blood pressure-lowering medication especially ACE inhibitor or ARB?
*
Yes
No
18. Do you have diabetes?
*
Yes
No
19. Have you continuously used corticosteroids for more than two weeks to control chronic inflammatory diseases?
*
Yes
No
20. Have you ever been diagnosed with cancer?
*
Yes
No
21. Are you receiving chemotherapy or radiotherapy?
*
Yes
No
22. Have you had organ transplantation recently?
*
Yes
No
23. Are you under treatment for Acquired Immunodeficiency Syndrome (AIDS)?
*
Yes
No
24. Do you have any primary immunodeficiency disorder?
*
Yes
No
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