Respiratory Infection Screening Form
Today's Date
-
Month
-
Day
Year
Date
Your Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
1. Have you been to another country in the recent 14 days?
Yes
No
2. Which of the following symptoms related to respiratory infection do you have?
Fever
Cough
Shortness of breath
No symptoms
Other
3. Are there anyone near you suffering from the above symptoms and has travelled abroad in the recent 14 days?
Yes
No
Submit
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