Visitor
Symptom Monitoring Form for Influenza-like / Caronavirus symptoms
1
Purpose of Visit
Visiting
Please specify your destination...
Ampath
Lancet
Radiology [Burger]
Pharmacy
General Visitor
2
Personal Information
Name
Surname
ID Number*
Cell number*
Are you a healthcare worker?*
YES
NO
3
Are you experiencing any of the following symptoms?
Current Temperature °C
Fever or Chills?*
YES
NO
Is it out of the normal?
YES
NO
Cough?*
YES
NO
Is it out of the normal?
YES
NO
Sore Throat?*
YES
NO
Is it out of the normal?
YES
NO
Shortness of Breath or any difficulty of breathing?*
YES
NO
Is it out of the normal?
YES
NO
Body Aches?*
YES
NO
Is it out of the normal?
YES
NO
Redness of the eyes?*
YES
NO
Is it out of the normal?
YES
NO
Loss of smell OR loss of taste?*
YES
NO
Is it out of the normal?
YES
NO
Nausea/vomiting/diarhoea?*
YES
NO
Is it out of the normal?
YES
NO
Fatigue/weakness?*
YES
NO
Is it out of the normal?
YES
NO
4
History
Have you been outside South Africa in the past 3 weeks?*
YES
NO
Have you had close contact with a confirmed or suspected COVID-19 case?*
YES
NO
Do you use any substance, drugs, alcohol and/or cigarettes?*
YES
NO
Do you have any co-morbidities?*
YES
NO
Have you has a COVID-19 test done in the past 72 hours?*
YES
NO
At which laboratory?*
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.
