Coronavirus Daily Health Check Form Your Full Name* Your Email* Is there a health care worker living in your household?* YesNo Do you have symptoms of coronavirus? A high temperature, a new continuous cough or loss of taste and smell?* YesNo If Yes, you must not come to work. You must self-isolate for 7 days. Please click here for further guidance on what to do next. Do you live with someone that has symptoms of coronavirus?* YesNo If Yes, you must not come to work. You must self-isolate for 14 days. Please click here for further guidance on what to do next. Have you within the last 10 days returned from a country which would require you to self-isolate on entry to the UK?* YesNo Have you within the last 10 days been instructed to self-isolate by NHS Test & Trace or any public health or medical professional?* YesNo Are you one of the vulnerable groups?* • Over 70 • Under 70 and have an underlying health condition • Pregnant YesNo If yes please contact us Have you had a Coronavirus test in the last month?* YesNo Please enter the date of your test* Was your test negative or positive?* NegativePositive Your Message I confirm I have answered these questions truthfully and I understand I may be prosecuted if I knowingly give false information. Yes Share This: