COVID-19 FORM :: The Mirror House

COVID-19 QUESTIONNAIR

Please complete the following questions

Have you, or anyone in your family, been diagnosed with COVID-19? If yes, please advice DATE *:

Have you, or anyone in your family, been tested for COVID-19? If yes, what was the result? *:

Have you, or anyone in your family, traveled in the past 14 days to any regions affected by COVID-19 or COVID-20? *:

Are you (or any one in your family) is isolating or quarantining because you/they may have been exposed to a person(s) with COVID-19 or COVID-20 or are worried that you (or any one in your family) may be sick with COVID-19 or COVID-20? *:

Within the past 14 days, have you (or any one in your family) been in close physical contact with:Anyone who is known to have laboratory-confirmed COVID-19 or COVID-20? OR Anyone who has any symptoms consistent with COVID-19 or COVID-20? *:

Have you, or any one in your family, experienced any of the following symptoms in the past 48 hours : Fever or chills? Cough? Shortness of breath or difficulty breathing? Fatigue? Muscle or body aches? *:

Have you, or any one in your family, experienced any of the following symptoms in the past 48 hours : Headache? Loss of taste or smell? Sore throat? Congestion or runny nose? Nausea or vomiting? Diarrhea? *:

Have you been vaccinated against COVID-19? If yes, please advise date *:

Please let us know the date and time you wish to book your appointment *:

Please advise number in your group (please specify Adults/Kids (age of children) *:

Please write your WhatsApp/Mobile number *:

COVID-19 QUESTIONNAIR

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