Covid-19 Entry Questionnaire

Full Name *

Email *

Mobile Number *

Current Temperature *

Have you been sick in the last two weeks? *

Yes

No

Do you have fever? *

Yes

No

Do you have a cough? *

Yes

No

Do you have a sore throat? *

Yes

No

Do you have a runny nose, blocked nose? *

Yes

No

Do you have tiredness, body ache? *

Yes

No

Have you lost your sense of smell or taste? *

Yes

No

In the last 20 days, have you been in contact with someone who has had these symptoms? *

Yes

No

In the last 20 days, have you traveled internationally or nationally? *

Yes

No

In the last 20 days, have you been in contact with someone who has covid19? *

Yes

No

Does someone in your house have the symptoms of Covid19 or has someone been diagnosed with symptoms? *

Yes

No

If you have had covid19, have you had the blood test to show that you have recovered? *

Yes

No

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.

Yes

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