Ashford Clinic

Pre-NAS Assessment Form

Full Name

Date of Birth (dd/mm/yyyy)

PPS Number

Address

Eircode

Mobile Number

Please tick whichever symptoms you are experiencing. Fever Cough Shortness of Breath Sore Throat Coryza (Runny Nose) Diarrhoea Aches & Pains

Length of Symptoms

Severity of Symptoms

Recent Travel Details - Please describe any recent travel you may have undertaken.

Have you had contact with a confirmed case?

Have you any Underlying Medical Conditions

Are you a heathcare worker?

Are you self-isolating?

Other Concerns:

On receipt of the form, you will receive confirmation from us. If you meet the criteria for testing we will make a referral to the NAS ( they will contact you directly to give you further information )

If your symptoms worsen while awaiting testing please contact us.

Please do not attend the surgery. Please continue to follow all publicized advice from the HSE if you have any concerns 1850 241850

Covid 19 Assessment Form