COVIDA.ie – Urgent Covid Testing FREE

From – Dr. Liam REGAN (www.Nassau.ie) Nassau Clinic, Weekend Doctor

Please complete our COVID-19 Pre-Test Questionnaire – it will take you 2 minutes to complete. The Doctor will review your answers and contact you later today (usually within 1 hour) to discuss whether you meet the criteria set by the Health Service Executive (HSE) to qualify to be tested.

COVID Test Questionnaire

Pre-Consultation Patient Questionnaire

Book Now via https://www.nassau.ie/book
Note - This a TELEPHONE CONSULTATION (not Face-To-Face)
PPSN + EIRCODE + CONSENT - do you have (a) your PPSN (b) your EIRCODE and (c) do you consent to the information you provide being shared with the HSE & DEASP?*
- YES
- NO
YOU CANNOT CONTINUE WITHOUT (a) PPSN (b) EIRCODE and (c) GIVING CONSENT
1 of 5 - Patient Details
Patient's Family Name / Surname?*
Patient's First Name?*
PPSN - Personal Public Service Number*
7 numerical characters followed by 1 alphabetical character (Note - sometimes there are 2 alphabetical characters)
Patient's Date of Birth*
DAY ****** MONTH **** YEAR
What is your 7 character EIRCODE?*
VERY IMPORTANT - the emergency health services WILL need an accurate EIRCODE to locate you. If it is not correct this form will not be processed. You can find your EIRCODE (which is 7 characters long) using the following link https://finder.eircode.ie/#/ If you are staying at a hotel or AirBnB ask your host for the EIRCODE.
SEX*
- Female
- Male__
- Other_
What COUNTRY is patients Mobile Telephone from:
- Ireland
- Another Country
Ireland Mobile Prefix*
- 083
- 085
- 086
- 087
- 089
Last 7 digits (after 083 / 085 / 086 / 087 / 089)*
Check that the telephone number is accurate as we will not answer calls from any other number or from a Private Number (where the caller ID is switched OFF)
Patient's Cellphone / Mobile Telephone Number (include Country Code)?
Check that the telephone number is accurate as we will not answer calls from any other number or from a Private Number (where the caller ID is switched OFF)
Email*
Have you been tested for the Coronavirus / COVID-19 Disease?*
- No - I never was tested
- Yes - I am still waiting for my result
- Yes - I am negative (I do NOT have the virus)
- Yes - I am positive (I DO have the virus)
2 of 5 - Patient's GP (Doctor's Name & Medical Clinic)
Who is your GP Doctor - Name & Medical Centre?*
Who was the Doctor that you last attended - Name & Medical Centre?*
When did you last attend a Doctor or Medical Clinic?*
- 1 month ago
- During past 6 months
- >1 year ago
- NEVER visited a Doctor or Medical Clinic in Ireland.
3 of 5 - COVID-19 Risk Factors
Prior to onset of your symptoms have you been in contact (in the past 14 days) with a person who was confirmed to have COVID-19?
- YES
- NO
In respect of the person that was confirmed as having COVID-19 is any of the following true:
- I was less than 2 metres from them
- I spend more than 15 minutes with them
What is your temperature NOW?*
- 36-36.9°C
- 37-37.9°C
- 38.-38.9°C
- 39-39.9°C
- >=40°C
Do you have a cough?*
- YES
- NO
Describe your cough*
Do you have shortness of breath?*
- YES
- NO
Describe your shortness of breath*
Have you an ALLERGY to any MEDICATION?*
- YES
- NO
List ALL medication that you are allergic to:*
Please outline any significant pre-existing medical conditions that may put you in an at-risk category
When did symptoms start?*
- I have NO SYMPTOMS
- 1-3 days ago
- 4-7 days ago
- More than 1 week ago
How severe are your symptoms?*
- Mild
- Moderate
- Severe (please call an ambulance on 112 or 999)
Are you a health care worker?
- YES
- NO
Name the facility, location and your responsibilities?*
Are you pregnant?
- YES
- NO
Do you smoke cigarettes or vape?*
- YES
- NO
- Ex Smoker
Do you have ISCHAEMIC HEART DISEASE?
- YES
- NO
Do you have HYPERTENSION?
- YES
- NO
Do you have CEREBROVASCULAR disease?
- YES
- NO
Do you have TYPE II DIABETES?
- YES
- NO
Are you OBESE?
- YES
- NO
What is your WEIGHT in KG?
What is your HEIGHT in CM?
In last 5 years have you ACTIVE MALIGNANCY?
- YES
- NO
Do you have chronic LUNG disease?
- YES
- NO
Do you have chronic RENAL disease?
- YES
- NO
Do you have chronic LIVER disease?
- YES
- NO
Are you IMMUNOSUPPRESSED?
- YES
- NO
Please provide details of your decreased immunity?
Are you a staff member or resident of a NURSING HOME?
- YES
- NO
Are you a staff member or resident of a RESIDENTIAL CARE SETTING?
- YES
- NO
Are you in DIRECT PROVISION, HOMELESS, ROMA or TRAVELLING COMMUNITY?
- YES
- NO
Are you a staff member or resident of a PRISON?
- YES
- NO
Does any one of your Household Contacts (people sharing your house) (i) work as a Health Care Worker or (ii) belong to an "At-Risk" Group (described below)
- YES
- NO
A person sharing your house is in an "At-Risk" Group if they suffer from Ischaemic Heart Disease, Hypertension, Cerebrovascular Disease, Type II Diabetes, Obesity, Active Malignancy in the last 5 year, chronic lung disease, chronic renal disease, or chronic chronic liver disease.
Please provide more details of the health of those with whom you share a house?*
TRAVEL - In the past 30 days have you been outside of the island of Ireland?*
- YES
- NO
Please click each one of the following places that you visited (or transit through):
- China
- Hong Kong
- Iran
- Japan
- South Korea
- Singapore
- Europe
- Another country not listed above
What other country / continent did you visit?
Please click each one of the following European places that you visited (or transit through):
- Italy
- France
- Germany
- Spain
- Britain
- Other European countries not listed above
What other European countries did you visit?
4 of 5 - Who is responsible for arranging this medical consultation?*
- PERSONAL - I am responsible for making this booking.
- INSURANCE - my insurance company is responsible for making this booking
What is the name of your insurance company?*
5 of 5 - Entitlement to COVID-19 Payments of €350 per week.
If the Doctor directs you to self-isolate, you may be entitled to a COVID-19 payment of €700 (€350 per week for 2 weeks) from the Department of Employment Affairs and Social Protection (DEASP) on condition that the Doctor issues a “Medical E-Certificate of Incapacity for Work” to the DEASP.
If the Doctor directs you to self-isolate do you want us to send a “Medical E-Certificate of Incapacity for Work” to the DEASP?*
- No
- Yes
For additional information on "Medical E-Certificate of Incapacity for Work" visit our website https://www.nassau.ie/medical-certificate

COVID Test Questionnaire

Book Now via https://www.nassau.ie/book

Note - This a TELEPHONE CONSULTATION (not Face-To-Face)

YOU CANNOT CONTINUE WITHOUT (a) PPSN (b) EIRCODE and (c) GIVING CONSENT

1 of 5 - Patient Details

2 of 5 - Patient's GP (Doctor's Name & Medical Clinic)

3 of 5 - COVID-19 Risk Factors

5 of 5 - Entitlement to COVID-19 Payments of €350 per week.