COVID-19 Screening Form

For your own benefit please provide truthful information


Signs and Symptoms

Please Input Name.
Please Input Surname.

Please Input Age.Please Input Number Format.

A. Having fever ≥ 37.5oC or have had history of fever


B. Having one or more of the following Respiratory symptoms (If no symptom, you may skip this question)
   
   
   
   
   


C. Having the following history in the past 14 days before the onset of symptoms (Exposure Risk)
C-I
1) 1) Patient has history of travelling to/ from/ live in a COVID-19 outbreak area




2) Having history of being in close contact (Click to read detail) with COVID-19 positive result

   
   


3) 3) Having history of being in crowded areas, contact with large number of people or community areas with reported confirmed cases of COVID-19 such as market, shopping center, healthcare facility or public transportation (Click for risk areas)



C-II
1) Having an occupation that relates to crowded areas or contact with large number of tourists


2) Having history of being in crowded areas, contact with large number of people or community areas such as markets, shopping centers, healthcare facility or public transportation


3) Having history of being in areas with a group of 5 or more people with respiratory symptoms in the same place within the last week


D. Medical staff (who were in contact with patient who is suspected or confirmed with COVID-19 in the past 14 days prior to onset symptom or medical staff from other healthcare facility)