COVID-19 Health Declaration Form
Full Name
*
First Name
Last Name
Address
*
Street Address*
Street Address Line 2
City*
State / Province
Postal / Zip Code
Mobile Number
*
E-mail
*
example@example.com
1. Do you have cough?
*
Yes
No
2. Do you have cold? *
*
Yes
No
3. Do you have sore throat?
*
Yes
No
4. Are you having diarrhea?
*
Yes
No
5. Are you experiencing body aches?
*
Yes
No
6. Do you have headache?
*
Yes
No
7. Are you having difficulty breathing?
*
Yes
No
8. Are you experiencing fatigue?
*
Yes
No
9. Have you traveled recently during the past 14 days?
*
Yes
No
10. Do you have a travel history to a COVID-19 infected area?
*
Yes
No
11. Do you have direct contact or is taking care of a positive COVID-19 patient?
*
Yes
No
12. What line of work are you in?
*
Yes
No
Submit
Should be Empty: