PHILRADS

Philippine Relief and Development Services Inc.

Full Name

Mobile Phone Number

Address Line 1

Address Line 2

E-Mail

Gender Male

Female

Do you currently have fever reaching 38°C? Yes

No

Do you have a sore throat? Yes

No

Do you have a cough Yes

No

Do you have a cold? Yes

No

Do you find it difficult to breathe Yes

No

Have you been suffering from stomach pain or Diarrhea ? Yes

No

Have you been feeling nauseous and/or vomiting? Yes

No

Did you travel abroad in the past 14 days? Yes

No

Have you had interaction with confirmed CO-VID-19 patients? Yes

No

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