Telehealth Consultation Assessment Form
for FLU and COVID-19 like symptoms



The assessment is free of charge to Alliance-MidMed members.



Please tick the reason most appropriate for doing this online assessment:






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Alliance Member Details

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Demographical Information

Gender:

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COVID-19 Assessment

Have you travelled outside of South Africa in the past 14 days?

Within the last 14 days, did you have direct contact with someone known to have contracted the Coronavirus disease (COVID-19)?

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Current Complaints

Do you have a cough?

Is your cough?

How long have you been coughing?


Have you taken any medication for your cough?


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Do you have a fever?

Please indicate the temperature:

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Do you have a sore throat?

How long has your throat been sore?


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Have you had shortness of breath or any difficulty breathing?

How long?

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Do you have any of the following symptoms? (Tick appropriate box)?

Running/Blocked nose

Nausea/Vommiting

Diarrhea

Body Pains

General Weakness

Confusion

Other
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Medical History

Do you have any allergies?

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Are you pregnant?

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Are you suffering from any severe illness?

Do you suffer from:

Asthma

High Blood Pressure

Diabetes

HIV

Cholestrol

Tuberculosis

Emphysema

COPD (Chronic Obstructive Pulmonary Disease)

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Do you smoke?

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Telemed Consultation Disclaimer

Should you require a telephone consultation, can one of our registered Healthcare Practitioners consult you?


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This assessment does not replace a professional medical consultation with a doctor or nurse. Please call us on 0860 002 101 if you have flu-like symptoms or if you are concerned about your current wellbeing so that we can assist you to receive access to the appropriate care and advice. This is particularly important if you have been in contact with someone who has COVID-19. Alternatively, please contact the National COVID-19 hotline on 0800 029 999 for guidance on what to do next should you not be able to get hold of us. Always seek a second opinion from a healthcare professional should you be at all concerned.

Do you accept the disclaimer?