Covid-19 Questionnaire

Have you or any family remember in the house hold been tested COVID-19 positive? YesNo

Do you have the following sign and symptoms?

Sudden onset of a cough YesNo

A sore throat YesNo

Shortness of breath YesNo

Fever / Chills YesNo

Sudden diarrhoea YesNo

Loss of smell and taste YesNo

General malaise / fatigue YesNo

Redness of eyes YesNo

I hereby declare that the above is correct and true.

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