Contact Details
Full Name
*
(as in passport)
CPR
*
Passport Number
If you do not have a CPR number please provide the passport number in this field
Phone Number
*
Bahraini number
Format: 00000000.
Gender
*
Male
Female
If female
Pregnant
Post-partum (up to 6 weeks)
Not pregnant or post-partum
Date of Birth
*
-
Day
-
Month
Year
Date
Home Address
*
House
Block
Road
City
Please place the pin on your home address
Are you married?
Yes
No
Do you have children?
Yes
No
How many people do you live with?
*
Who are they?
Are you a healthcare worker?
Yes
No
Who is your employer?
*
What is your occupation?
*
Medical History
Do you have any of the following conditions?
*
Chronic respiratory disease
Asthma
Diabetes
Chronic cardiac disease
Chronic renal disease
Chronic liver disease
Chronic neurological impairment
Immune compromised
Obesity
None of the above
Other
Have you experienced the following symptoms?
*
Fever
Cough
Shortness of breath
Runny nose
Headache
Body pains
Diarrhoea
None of the above
Other
When did you begin to feel symptoms?
Do you drink alcohol?
*
Yes
No
Do you smoke?
*
Yes
No
COVID-19 Test
Date of last known exposure
-
Month
-
Day
Year
Date
Have you been tested for COVID-19?
*
Yes
No
Which area/center were you tested in?
*
When were you tested?
*
-
Day
-
Month
Year
Date
Why were you tested?
*
I developed symptoms and was referred by 444
I developed symptoms and visited a medical facility
I am a close contact of someone who tested positive
I have completed my 14 day quarantine period
Random testing
Other
Have you been identified as a contact of a positive case?
Yes
No
Please identify the individual
History of Activity
Kindly list all the places that you recall visiting in the past 14 days with the date of visit
Have you visited a healthcare facility in the past 14 days?
*
Yes
No
Healthcare facility visited
Have you visited a gathering of more than two people in the past 14 days?
Yes
No
Gathering visited
Other locations visited
Do you have any history of travel?
*
Yes
No
Flight Number
From
Date of Arrival
-
Day
-
Month
Year
Date
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Have you had any contact with anybody who has history of travel?
Yes
No
Do you know this person?
*
Yes
No
Flight Number
From
Date of Arrival
-
Day
-
Month
Year
Date
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Please identify the individual
Interactions
Kindly list all 1) names, 2) phone numbers, and 3) CPRs (if available) of the individuals you have interacted with within the past 14 days, as well as 4) specify when those interactions occurred
Family Member
Workplace
Others
Submit
Geolocation
*
Should be Empty: