Healthscreening-rst - Viroclinics

1. Did you have problems with coughing during the past 2 hours?*

No
Yes

2. Have you had a cold during the past 24 hours?*

No
Yes

3. Have you had a fever (more than 38° C) during the past 24 hours?*

No
Yes

4. Did you experience shortness of breath in the past 24 hours?*

No
Yes

5. Do you currently have a roommate with a fever and / or shortness of breath?*

No
Yes

6. Have you had the coronavirus and has it been diagnosed in the past 7 days?*

No
Yes

7. Do you have a roommate / family member with coronavirus and did you have contact with him / her during the past 14 days while he / she still had complaints?*

No
Yes

8. Are you in home isolation because you have had direct contact with someone diagnosed with the coronavirus?*

No
Yes

Full name*

Mobile phone

Date of visit*

Time of visit*

:

Contact Person Viroclinics*

Reason for visit*

By filling out this Health Screening Form for Visitors, the visitor expressly acknowledges and agrees in sharing this information with Viroclinics-DDL upon their specific request for the sole purpose of tracing in case of a possible local spread of the COVID-19 virus. These data and information will be deleted after 14 calendar days.

Viroclinics

Please answer the following questions