CORONAVIRUS Health Questionnaire

Please answer the following questions honestly and in the best interests of our patients, staff, and doctors.

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Have you travelled to any one of the destinations below in the last 21 days?

In the last 14 days have you been in close contact with a confirmed COVID-19 patient or a person under investigation for COVID-19?

Are you experiencing any difficulty in breathing?

Please tick any one of the following symptoms that applies to you.

Do you have a fever higher than 38°C or a history of fever?

Do you have a cough?

Are you experiencing muscle aches, weakness, or lightheadedness?

Are you having diarrhoea, stomach pain, vomiting?

Do you have a sore throat?

Have you been in close contact or living with anybody with flu-like symptoms?

Have you been in close contact with somebody with flu-like symptoms and a negative or inconclusive COVID-19 test result?

Have you worked or attended a health care facility where COVID-19 patients are treated?

Have you been admitted to hospital with severe pneumonia in the last 14 days?

Please fill with your personal data

Thank you for your time
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