Survey COVID-19

Do you suffer from heart, lung, kidney or liver problems ?

YesNo

Do you have unbalanced diabetes ?

YesNo

Do you have a medical condition or treatment that lowers your immunity ?

YesNo

Do you have any other health problems ?

YesNo

Are you pregnant in your third trimester ?

YesNoNot applicable

To date and in the last 3 weeks have you had any of the following symptoms :

Fever (>38°C)Breathing difficultySudden loss of tasteSudden loss of sense of smellSore throatDiarrhoeaDry coughBody achesHeadachesNausea, vomitingNone

In the last 14 days, have you been in close contact with :

- a person with these symptoms ?

YesNo

- a person diagnosed with COVID-19 ?

YesNo

Have you been tested positive for COVID-19 ?

YesNo