COVID-19 Questionnaire | Down Syndrome Limerick

Please fill in the questionnaire below with your details.
Please complete within 24 hours prior to arrival at Down Syndrome Limerick.

Do you have any symptoms of Covid-19 now or in the last 14 days (see table below)?
YesNo

Have you been diagnosed with confirmed/suspected COVID-19 in the last 14 days?
YesNo

Are you a close contact of a person who is a confirmed/suspected case of COVID-19 in the past 14 days?
YesNo

Have you or any member of your family been advised by a doctor to self-isolate at this time?
YesNo

Declaration:
I declare that the above information provided by me is true, accurate and complete in all respects.

Please do not attend the service if you answer Yes to any of the above questions. While we understand this might cause an inconvenience to you, we are acting in the best interest of all of our members.

Symptoms of Covid-19::

Common Symptoms	Less Common Symptoms	Severe Symptoms
Fever (temperature > 38C)	Change to sense of smell	Shortness of breath
Chills	Change to sense of taste	Loss of appetite
Dry cough	Nasal congestion	Confusion
Fatigue	Conjunctivitis	Chest pain/pressure
	Sore throat
	Headaches
	Muscle of joint pain
	Skin rash
	Nausea, vomiting or diarrhoea
	Dizziness

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.