Coronavirus Self-Assessment Form

A self-assessment questionnaire that helps patients evaluate their COVID-19 exposure risk and symptoms, including emergency contact details for follow-up.

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Name

Nombre

Apellido

Personal Email

Home Country

Country/Location when filling out this form.

Home Address

Dirección

Ciudad

Estado / Provincia

Código postal

Have you been to one of the COVID-19 affected countries in the last 14 days?

Yes No

Please specify details of the cities/countries visited in the last 14 days.

Have you been in close contact with a confirmed case of coronavirus?

Yes No

Are you currently experiencing symptoms (cough, shortness of breath, fever)?

Yes No

Please specify details of the symptoms

Emergency Contact Name

Nombre

Apellido

Emergency Contact Phone

Additional Comments

Signature

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Coronavirus Self-Assessment Form

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