COVID Safety Form - COVID19 Questionnaire

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Name

Contact Number

Email

History Of Travel In The Last 2 Weeks

Yes No

History of flu like symptoms : low grade fever, body aches , runny nose, dry cough, generalized malaise ?

History of any contact with Covid Positive patients in the last 14 days ?

Yes No

History of any family member having Flu like symptoms ?

Yes No

Have you been advised Screening for Covid or Quarantine ?

Yes No

Are you above 60 years of age?

Yes No

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