Covid Risk Assessment Tool | Libertatem Healthcare

Your Name*
First Last
Today's date*
Date Format: MM slash DD slash YYYY
Age: COVID 19 seems to have a bigger impact on people who are older*
- If you are aged 49 or under - Score 0 Points
- • If you are aged 50-59 - Score 1 Point
- • If You are aged 60-69 - Score 2 Points
- • If you are aged 70-79 - Score 4 Points
Please tick the box that applies to you
Sex at birth COVID 19 seems to have a bigger impact on males than females
- Female - Score 0 Points
- Male - Score 1 Point
Please tick the box that applies to you
Ethnicity – COVID-19 seems to have a bigger impact on people from some ethnicities*
- • Do you identify as one of the Black, Asian and Minority Ethnic or Mixed race groups - Score 1 Point
- I do not identify as one of the above groups - Score 0 Points
Existing Health conditions (Comorbidity COVID 19 seems to have a bigger impact if you already have other pre-existing health conditions. You may want to speak to your GP if you are not sure about these questions*
- • Cardiovascular disease Are you on any treatment for Hypertension (high blood pressure), Atrial Fibrillation (Irregular heart rate), Heart Failure, Previous MI (had a heart attack), had a stroke, or Transient Ischemic Attack (mini stroke) - Score 1 Point
- • Diabetes Mellitus Type 1 or 2 - Score 1 Point
- • Chronic lung disease (including asthma, COPD, interstitial lung disease) - Score 1 Point
- • Chronic kidney disease (any stage 1 5) - Score 1 Point
- • Sickle cell trait, Thalassaemia trait or other haemoglobinopathy - Score 1 Point
- None of the above - Score 0 Points
Obesity COVID 19 seems to have a bigger impact if you are overweight*
- • South Asian Female less than 33 inches (84cm ); Other BAME or white Female less than 34.5 inches (88cm) - Score 0 Points
- • South Asian Female more than 33 inches (84cm ); Other BAME or white Female more than 34.5 inches (88cm) - Score 1 Point
- • South Asian Male less than 35 inches (89cm ); Other BAME or white Male less than 40 inches (102cm) - Score 0 Points
- • South Asian Male more than 35 inches (89cm ); Other BAME or white Male more than 40 inches (102cm) - Score 1 Point
Please tick the most appropriate box for you. If your waist circumference is:
Family history COVID 19 seems to have a family susceptibility for some people, especially twins*
- • Has a member of your immediate family (parent, sibling, child) been in ITU or died with COVID-19 - Yes - Score 1 Point
- • Has a member of your immediate family (parent, sibling, child) been in ITU or died with COVID-19 - No Score 0 Points
Please tick the appropriate box for you
Please add together your total score and enter in the box below*

Covid 19 Risk Assessment Tool