CORONAVIRUS TRAVEL HISTORY CONTACT QUESTIONAIRE - 在线考试测评模板

CORONAVIRUS TRAVEL HISTORY CONTACT QUESTIONAIRE

Dear Visitor For Triage vigilance and compliance with local health requirements, kindly complete this questionnaire before entry into our clinic

Q1:Name

Q2:Do you have the following symptoms in the last 5 daysFever/Shortness of Breath/CoughNasal Congestion/Runny Nose Sore Throat/Fatigue/DiarrheaAbnormal sense of smell and taste

yes

Q3:Is your 48h PCR test result Positive?

yes

Q4:Did you have contact with individuals who have been diagnosed or has beensuspected of having been infected with Covid-19 virus in the last 7days?

yes

Q5:Did you travel or have resided in middle or high risk areas in the last 7 days?

yes

Q6:Are you currently under “Home Quarantine” for medical observation?

yes

Q7:I hereby declare that the above information provided is true as reported.

Passport:

Phone:

Date:

:* Note : Information declared in this questionnaire is deemed true as reported. You can be liable to legal responsibilities should the information be untrue and has caused severe consequences.