COVID -19 Health Check Newborn Love

Question Title

* 1. NAME

Question Title

* 2. Please tick if you or any member of your family have the following symptoms in the last 7 days.

High temperature

Continuous or new cough

Loss of smell or taste

None of the above

Question Title

* 3. Have you knowingly been in contact with anyone who has the above-listed symptoms?

Yes

No

Question Title

* 4. Have you been in contact with anyone who has tested positive for COVID 19 in the last 7 days?

Yes

No

Question Title

* 5. Have you or anyone you have been in close contact with travelled from overseas in the last 14 days?

Yes

No

Question Title

* 6. Have you or any member of your family been advised to shield?

Yes

No