| SCREENING PATIENT QUESTIONNAIRE COVID-19 | |
|---|---|
| Sex | (Male / Female) |
| Age | (Years) |
| Living address | (City - Country) |
| Travel in the past 6 months | (Yes / No - Where) |
| Self-perceived health status | (Very good, good / Fair / Very bad, bad) |
| Medical consultation in the past 14 days? | (Yes / No) |
| Presence of fever (>37.5°), cold, cough, respiratory symptoms, muscle pain, headache in the last 14 days | (Yes / No) |
| Have you been in contact with people with these symptoms for the past 14 days? | (Yes / No) |
| Have you been in contact with infected people in the past 14 days? | (Yes / No) |