Health Declaration Form
Name
*
Mobile Number
*
Date
*
DD slash MM slash YYYY
Company
*
1) Do you have any of the following symptoms?
a) Fever
*
Yes
No
b) Sore throat
*
Yes
No
c) Cough
*
Yes
No
d) Breathlessness
*
Yes
No
2) Have you travelled outside India in last 2 months?
*
Yes
No
3) Have you been in contact with a person who has travelled outside India in the past 2 months?
*
Yes
No
4) Have you been in contact with a COVID-19 positive patient?
*
Yes
No
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*
First
Email
*
Phone
Date
*
MM slash DD slash YYYY
Time
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5PM
6PM
7PM
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Email
*
Mobile Number
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