Oral and Maxillofacial Surgery Outpatients

Level 2 Main Building

John Radcliffe Hospital
Headley Way
Headington
Oxford
OX3 9DU

01865 743112

COVID-19 Screening Questionnaire

Please read the following questions. If your answer is ‘yes’ to any question, then please contact
the department 48 to 72 hours before your appointment either by email oral.surgery@ouh.nhs.uk
or phonecall to 01865 743112, to provide further information.

Please note you will also need to contact the department if you have been advised to shield by
the government or your GP.
Response
1) Have you tested positive for COVID-19 in the last 7 days? Yes No

2) Are you waiting for a COVID-19 test or the results? Yes No

3) Do you have any of the following symptoms:

a. New, continuous cough* Yes No

b. High temperature or fever Yes No

c. Loss or change in sense of smell or taste Yes No

4) Do you live with someone who has either tested positive for Yes No
COVID-19 or had symptoms of COVID-19 in the last 14 days?

5) Have you been notified by NHS Test and Trace in the Yes No
last 14 days that you are a contact of a person who has
tested positive for Covid-19 and you do not live with that
person?

* A new, continuous cough means coughing for longer than an hour, or 3 or more coughing episodes in
24 hours. If the patient usually has a cough, it may be worse than usual.

Note: If the patient has symptoms of COVID-19, they will need to self-isolate for 7 days

Use the NHS 111 online coronavirus service to find out what to do

Advise for patient who lives with someone who has COVID-19 symptoms:

 You will need to self-isolate for 14 days from the day their symptoms started. This is because it can take 14 days for symptoms to
appear.
 If you have more than 1 person at home who has symptoms, self-isolate for 14 days from the day the first person started having
symptoms.
 If you get symptoms, self-isolate for 7 days from when your symptoms start, even if it means you’re self-isolating for longer than 14
days.
 If you do not get symptoms, you can stop self-isolating after 14 days