COVID-19 Self-assessment questionnaire

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The molecular (PCR) test for COVID-19 is considered Prescribed Minimum Benefit (PMB) level of care on referral from a healthcare worker who has screened the patient in terms of the National Institute of Communicable Diseases (NICD) criteria. Profmed’s Designated Service Provider Network (DSPN) for screening consultations is General Practitioners (GPs). The Scheme will not cover consultations or screening done by any other healthcare worker. If the necessary NICD criteria are not met, testing will not be funded as it is considered to be “routine” testing, as defined by the Council for Medical Schemes.

This self-assessment will assist you in determining whether you should consult a GP to establish if you should be tested for COVID-19.

This assessment will be used in conjunction with the General Practitioner COVID-19 PCR Screening form from your GP, which must be submitted to the Scheme, to determine whether you qualify for benefits.

Section A: Personal Details


Section B: Patient Symptoms




Dry coughSore throatDifficulty breathingFever (temperature higher than 37.1°C)Loss of tasteLoss of smell

Section C: Patient Contributing Factors




Do you have any pre-existing conditions, e.g. Hypertension, Diabetes, Asthma, COPD, Cancer?Have you been in contact with someone within the last 14 days who tested positive for COVID-19?Have you travelled to a COVID-19 hotspot within the last 14 days?Have you travelled internationally or across the borders of South Africa within the last 14 days?

Section D: Next Steps


  • If you have selected two or more symptoms in Section B, together with one or more criteria in Section C, self-isolate for 10 days. No test is needed.
  • If you have been in close contact with someone with confirmed COVID-19, self-isolate for 10 days. No test is needed.
  • If you are feeling sick, stay at home.
  • In any of the above scenarios, if your condition deteriorates, contact your GP. Please call ahead, before visiting your GP.

I confirm that the information provided is true and accurate.