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) |