Name* First Last Date* DD slash MM slash YYYY High RiskAre any of the following high risk factors true for you?* Have had an organ transplant? Currently receiving treatment for cancer? Have a severe lung condition such as cystic fibrosis, severe asthma or severe COPD? Have a condition that puts you at a high risk of getting infections? Taking medicine that makes you more likely to get infections, such as high doses of steroids or immunosuppressants? Have a serious heart condition and are pregnant? None of the above, Moderate RiskAre any of the following moderate risk factors true for you?* Age 70 or over? Have a lung condition that's not severe such as asthma, COPD, emphysema or bronchitis? Have heart disease such as heart failure? Have diabetes? Have chronic kidney disease? Have liver disease such as hepatitis? Have a condition affecting the brain or nerves such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy? Have a condition that means you have a high risk of getting infections? Are taking medicine that can affect the immune system such as low doses of steroids? Have a BMI of 40 or above? Are pregnant? None of the above. Other Potential Risk FactorsAre any of the following other potential risk factors true for you? Your age - your risk increases as you get older? Being a man? Being from a Black, Asian or minority ethnic background? Bring born outside the UK or Ireland? Having certain jobs, such as nurse, social care, taxi driver and security guard? Not being vaccinated against COVID-19 Signature* Reset signature Signature locked. Reset to sign again
