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Date

Name of the person being screened*

This form is fill :*

Please indicate if the name below corresponds to the patients questionnaire or the person accompanying the patient?*

If attendant name of patient*

1- Have you had a positive COVID-19 screening test in the last 21 days or are you awaiting a screening test result?*

Have you experienced any of the following symptoms

2- Fever (over 38 °C or 100,4 °F)?*

3- Recent or chronic cough that has gotten worse?*

4- Difficulty breathing (e.g. shortness of breath or difficulty speaking)?*

5- Sudden loss of smell (with or without loss of taste)?*

6- Muscle pain, headache, intense fatigue or severe loss of appetite?*

7- Sore throat*

8- Diarrhea*

9- Have you been in close contact (at least 15 minutes within 2 meters) with a confirmed or probable case of COVID-19?*

Signature of the person who filled out the questionnaire*