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Name and surname
*
Identification code
*
Which of the following are you?
*
I am a patient
accompanying person
Have you or someone in your household been in contact with an infected COVID-19 person in the last 14 days?
*
yes
no
If your answer is YES, then who and when?
Do you have any of the following symptoms?
*
NO
temperature is higher than 37.5°C
cough
sore throat
breathing difficulties, dyspnea
loss of taste and smell
muscle pain
tiredness
hoarseness, runny or stuffy nose
Have you previosly been tested for COVID19 case? Was the test result positive?
*
yes
no
If your answer is YES, then when
Have you or any member of your household been travelling abroad in the last 14 days?
*
yes
no
If your answer is YES, then who, when and what country
Have you been vaccinated against COVID-19?
*
yes
no
Confirmation
*
I hereby declare that the information provided is true and correct.
Date
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