COVID-19 Questionnaire

Name *

First Name

Last Name

Do you currently have COVID-19 or are you experiencing any flu like symptoms? *

Yes

No

Have you travelled abroad in the last 14 days? *

Yes

No

Do you live in the same household or have you been in contact with someone who has displayed symptoms of COVID-19 in the last 14 days? *

Yes

No

Have you been advised to cocoon at this time? *

Yes

No

How are you feeling health wise? *

Well

Unwell

I hear by declare that the information provided is true and correct to the best of my knowledge *

Check this box to confirm