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COVID-19 SCREENING TOOL
Please select one
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Client
Employee
Visitor
Other
Other
Name
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Surname
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Date of birth
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Age
Home Address
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Home Location
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Select Province
Select District
Choose Municipality
Contact Number
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Alternative Contact
RISK ASSESSMENT
Have you been outside the province in the past 14 days
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Yes
No
Which Province?
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Have you met someone suspected COVID-19
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Yes
No
When
Were you required to isolate
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Yes
No
Have you experienced any of the following symptoms in the past 7 to 14 days?
Fever
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Yes
No
Cough
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Yes
No
Sore throat
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Yes
No
Difficulty breathing
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Yes
No
Body ache
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Yes
No
Loss of taste or smell
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Yes
No
Nausea or vomiting
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Yes
No
Other
Yes
No
Other symptom
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Temperature Reading
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