Corona Virus Screening Name *Email Address *Phone *ID *SexMaleFemaleStreet AddressTownProvincePostal CodeCurrent signs and symptoms (Tick if you have the symptom) FeverCoughShortness of breath Sore throatMuscle painLoss of taste or smellHave you traveled outside the province?YESNOWhich province ?GAUTENG FREE STATE NORTH WEST EASTERN CAPE WESTERN CAPENORTHERN CAPE MPUMALANGAKWAZULU NATALwhen did you travel ?have you been in contact with a person with a confirmed COVID 19 case ? YESNOIf yes explain.Have you attended a mass-gathering in the past 4 weeks ?YESNOwhere ?When ?Nature of Event :DateSubmit
