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116 Musgrave Park, 18 Musgrave Road, Musgrave, Durban
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Patient Covid-19 Questionnaire
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Date of Birth and ID Number
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What is your current temperature?
35 °C
35.5 °C
36 °C
36.5 °C
37 °C
37.5 °C
3.8 °C
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Have you travelled in the last 14 days? If yes, which place?
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Have you been exposed to anyone with the COVID-19 virus?
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Have you attended a healthcare facility where patients with COVID-19 infections are being treated?
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Have you experienced at least ONE of the following symptoms recently?
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Have you been hospitalised recently with severe Pneumonia?
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Do you currently have flu like symptoms?
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I hereby declare to the best of my knowledge that the information disclosed is correct at the time of completion. I further undertake to inform THE PERSON THAT I AM VISITING should i be diagnosed with COVID-19 within the next 14-days so as to facilitate contact tracing.
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