Coronavirus COVID-19

First Name *

Last Name *

Email *

Phone *

Patient Accompanying person - Name of patient

1. Are you currently in isolation due to a positive test result for COVID-19? *

Yes No

2. Has it been recommended that you take a screening test or are you awaiting a test result? *

Yes No

3. Have you been instructed to palce yourself in preventive isolation (e.g., returning from a trip abroad less than 14 days ago, contact with a confirmed case of COVID-19?) *

Yes No

Do you have any od the following symptoms:

4. Do you have a feeling of fever, chills like the flu, or a feaver, with a temperature taken by mouth, higher than 38oC (100.4oF), or than 37.8oC (100.0oF) for seniors *

Yes No

5. Do you have a new cough or a recently worsening chronic cough? *

Yes No

6. Do you have breathing difficulties? *

Yes No

7. Do you feel out of breath? *

Yes No

8. Have you noticed a sudden loss of smell (without nasal congestion) with or without loss of taste? *

Yes No

9. Have you a sore throat? *

Yes No

10. Do you have at least 2 of the following symptoms? *
• Headache
• Intense fatigue
• Muscle pain (not linked to physical exertion)
• Significant loss of appetite
• Nausea or vomiting
• Diarrhea

Yes No

11. Do you have a known health issue that might explain the symptoms described above? If so, specify *

Yes No

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Calculation for human identification:26-12 =

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