Are you experiencing any of these symptoms?

Select all that apply to you

Fever, chills or sweating

Sore throat

Difficulty breathing (not severe)

Dry cough

Body aches

Vomitting or diarrhea

Tiredness

None of the above

Do you have any underlying health condition?

Select all that apply to you

Asthma or lung illness

Pregnancy

Diabetets

Kidney Failure

Heart diseases

Extreme obesity

Liver failure

None of the above

In the last 14 days have you travelled internationally?

Yes

No

Have you been anywhere COVID - 19 is widespread?

Select all that apply to you

Yes

No

Have you had any close contact with any COVID - 19 patients?

Yes

No

Do you live or work near a care facility e.g hospitals, isolation centers?

Yes

No