Pre-Admission PatientSymptom Monitoring Form for Influenza-like / Caronavirus symptoms

1Personal Information
2Are you experiencing any of the following symptoms?

I hereby acknowledge that I have completed the form honestly and in my personal capacity.
Please note that if any of the above symptoms were selected it is your duty to inform the neccessary individuals and the necessary precautions should be taken. Your personal information may be disclosed when required by law to authorised entities.