Telehealth Consultation Assessment Form for FLU and COVID-19 like symptoms
Please complete the form below in full as all fields are mandatory.
Please keep in mind that the assessment is for Umvuzo Health members only.
Based on the results of the assessment, we will contact you with further guidance and care. The assessment is free of charge to Umvuzo Health members. Any possible consultation as a result of the assessment will be funded out of your available benefits.
Our out bound contact hours are from Monday to Sunday 8:00 to 16:00 including public holidays.
Based on the results of the assessment, we will contact you with further guidance and care. The assessment is free of charge to Umvuzo Health members. Any possible consultation as a result of the assessment will be funded out of your available benefits.
Our out bound contact hours are from Monday to Sunday 8:00 to 16:00 including public holidays.
Umvuzo Member Details
Demographical Information
Gender:
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)?
Current Complaints
Do you have a cough?
Is your cough?
How long have you been coughing?
Have you taken any medication for your cough?
Do you have a fever?
Please indicate the temperature:
Do you have a sore throat?
How long has your throat been sore?
Have you had shortness of breath or any difficulty breathing?
How long?
Do you have any of the following symptoms? (Tick appropriate box)?
Running/Blocked nose
Nausea/Vommiting
Diarrhea
Body Pains
General Weakness
Confusion
Other
Running/Blocked nose
Nausea/Vommiting
Diarrhea
Body Pains
General Weakness
Confusion
Other
Medical History
Do you have any allergies?
Are you pregnant?
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)
Asthma
High Blood Pressure
Diabetes
HIV
Cholestrol
Tuberculosis
Emphysema
COPD (Chronic Obstructive Pulmonary Disease)
Do you smoke?
General Practitioner Information
Should you require a telephone consultation, can one of our registered Healthcare Practitioners consult you?
Disclaimer *
This assessment does not replace a professional medical consultation with a doctor or nurse. Please call us on 0861 083 084 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?