COVID-19 Screening Form






    YesNo

    Waiting for the testWaiting for the resultI am considered a probable caseI have been asked to self-isolateNone of the above

    YesNo

    CoughSore throatShortness of breathRunny nose, sneezing, post-nasal drip (coryza)Loss of smell (anosmia)None of the above

    Fever onlyDiarrhoeaHeadacheMuscle painNausea/vomitingNone of the above

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo


    Yes