Coronavirus and General Health check form.

Coronavirus and General Health check form.

Use this form to report your symptoms and to minimise any potential risk to yourself and the community. If you have any clear Coronavirus symptoms we will endure to contact you so we can investigate further and if necessary provide immediate expert medical attention.
Name *

First NameLast Name
Current Spanish address*

Building/Resort/ Street no:

Town/ City

Country of residence.How long have you been in Spain?

Contact number in country of residence.
YesNo
When did you start to feel ill?
YesNo
FeverCoughDifficulties BreathingTiredWeakStomach IssuesExhaustion from normally simple tasks
Please specify details of symptoms/ illness you currently feel.*
YesNo
Personal Email*
example@example.com
Phone number/ skip if only mobile number available.

Area CodeMob./Phone Number
Mobile /Phone number*

Mob./Phone Number
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*

Area CodeMob/Phone Number
Name of person submitting this form if other than patient

First NameLast Name
Spanish law requires that you answer all questions correctly to the best of your knowledge. By submitting I hereby confirm that the information I have given above is true to the best of my knowledge. I understand my personal information will be kept confidential under compliance laws. I understand medical advice may be issued to me in order to prevent the spread of Coronavirus to others within the community and this advice must be strictly followed. We shall endure to solicite expert medical assistance to you if you may be a risk.
Signature/ Use mouse/ or finger on touch screens.
Last for SSN
To prevent duplicate reports
Should be Empty: