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Covid-19 Patient Evaluation Form






 


 
1. Do you have fever or experience fever within the past 14 days?
YesNo

2. Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing within the past 14 days?
YesNo

3. Have you, within the past 14 days, travelled overseas, or visited the neighbourhood with documented 2019-nCoV transmission?
YesNo

4. Have you encounter people who come from overseas, or people with recent documented fever or respiratory problems within the past 14 days?
YesNo

5. Are there at least two people with documented experience of fever or respiratory problems within the last 14 days having close contact with you?
YesNo

6. Have you recently participated in any gathering, meetings, or had close contact with many unacquainted people?
YesNo