COVID-19 FORM :: The Mirror House

COVID-19 QUESTIONNAIR

Please complete the following questions

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

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 are worried that you (or any one in your family) may be sick with COVID-19? *:

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 Anyone who has any symptoms consistent with COVID-19? *:

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? *:

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

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

Please advise number in your group. If you are a group of friends, each person MUST fill out the COVID-19 form and submit. *:

Please advice if you are one family or a group of friends *:

Family

Friends

If you are a family, please advice if kids are included: *:

Yes

If kids are included, please advice NUMBER and AGE: *:

Please write your WhatsApp/Mobile number *:

Please write your name *:

COVID-19 QUESTIONNAIR

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