Health Screening Questionnaire

Health screening questionnaire

Full name

Date

Have you experienced chest pain or discomfort in the last 7 days?

NoYes

Have you felt dizzy or fainted recently?

NoYes

Do you currently have a fever, cough or other signs of illness?

NoYes

Have you had a recent injury or surgery?

NoYes

Please briefly describe

This response will be flagged for staff review before you proceed.

Anything else we should know?

This form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.

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