COVID-19 screening Are you suffering from fever / high temperature or have temperature fluctuations? ---YesNo Do you have a dry cough? ---YesNo Do you have a sore throat? ---YesNo Do you have redness of eyes? ---YesNo Do you experience shortness of breath / difficulty in breathing? ---YesNo Have you got unusual body aches / muscle pain? ---YesNo Do you experience a loss of smell / taste? ---YesNo Are you nauseous and/or do you experience unusual vomiting? ---YesNo Have you got diarrhoea? ---YesNo Do you suffer from fatigue / physical weakness / tiredness? ---YesNo Have you tested positive for COVID-19 in the past 10 days? ---YesNo Were you exposed* to someone who is positively diagnosed with COVID-19, or to someone who is in quarantine / self-isolation for COVID-19 in the past 10 days? *Exposed in family or community setting is spending >15 minutes in infected person’s company AND being <1,5m apart AND not wearing a face mask. * Exposed in clinical setting is not wearing proper PPE, or PPE failure AND spending >15 minutes in infected person’s company AND being <1,5m apart. ---YesNo If you answered “YES” to any of the above questions then: i) Don’t attempt to enter this establishment; ii) Consult a healthcare professional to seek advice. Date of completion of form: By submitting this form, I acknowledge that I have answered the above questions truthfully and accurately.
