COVID-19 Health Status Daily Monitoring








     
     
    Have you attended mass gathering, a reunion of relatives/friends, parties within a month prior to this survey? *
    YesNo
     
    Have you been in close contact with a COVID-19 positive patient? *
    YesNo
     
    Have you been in close contact with a COVID-19 PUI/Probable patient? *
    YesNo
     
    Have you been in close contact with a COVID-19 PUM/Suspect patient? *
    YesNo
     
    Do you have a flu-like/respiratory symptoms? *

     
    Do you have pre-existing conditions? *

    If yes is your answer to the previous question, please specify:

     
    Do you take maintenance drugs? *
    YesNo
    If yes is your answer to the previous question, please specify:

     
    Are you pregnant? *
    YesNo
     
    Are you currently experiencing medical emergency? *
    YesNo
    If yes is your answer to the previous question, please specify:

     
     

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