Name

Surname

Phone number

E-mail

Do one of more of the following questions apply to you? Check the box 'YES' if applicable:

Did you have one or more of these complaints in the past 24 hours? A cough, a nose cold, a Faver from 38 degrees, shortness of breath. Yes

Do you currently have a roommate with a fever and/or shortness of breath? Yes

Did you have the coronavirus and has it been diagnosed in the past 7 days (in a laboratory)? Yes

Do you have a roommate/family member with the new coronavirus and have you had contact with him/her in the past 14 days while he/she still had complaints? Yes

Are you in quarantine because you had direct contact with someone who has been diagnosed with the new coronavirus? Yes

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