First Name

Last Name

Email Address

How old are you?

Under 18 18-60 60 Above

What is your gender?

Male Female

DO you have any travel history in the last month?

Yes No

DO you have a fever?

Yes No

Are you experinecing new or worsening dry cough?

Yes No

Are you suffering from any difficulty iin breathing?

Yes No

Have you had any close contact with someone diagnosed with Covid-19 or have any symptoms of Covid-19?

Yes No

Do you have any other disease e.g "Cancer\Sugar\T.B......?"