Screening/Disclosure Form For Patients

Please enter a number from 1 to 100.
MM slash DD slash YYYY
Do you have any symptoms of Fever, Cough, Sore throat, Fatigue, Sudden loss of smell/taste anytime during last 21 days ? *(Required)
Did you experience any difficulty in breathing anytime during last 21 days ? *(Required)
Do you have any exposure to a known or suspected case of Covid-19 patient in last 21 days ? *(Required)
Have you visited any other medical facility /hospital in last 21 days ? If yes, for what reason ? *(Required)
Are you residing in a locality that has been notified by the government as a covid containment zone ? *(Required)
Have you ever been tested for Covid-19 ?If yes, give details *(Required)
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