Bootstrap 5 Multi-Step Form

COVID-19

Self Checker Form

A clinical assessment multi-step form that will assist individuals on deciding when to seek testing or medical care if they suspect they or someone they know has contracted COVID-19 or has come into close contact with someone who has COVID-19

Have you recently been in close contact with someone who has COVID-19?

Yes

Are you experiencing a high fever, dry cough, tiredness and loss of taste or smell?

Yes

Are you having diarrhoea, stomach pain, conjunctivitis, vomiting and headache?

Yes

Have you traveled to any of these countries with the highest number of COVID-19 cases in the world for the past 2 weeks?

Brazil

Germany

India

Europe

I did not travelled to any of these countries

Are you experiencing any of these serious symptoms of COVID-19 below?

Difficulty breathing or shortness of breath

Chest pain or pressure

Loss of speech or movement

Pale, gray or blue-colored skin, lips or nail beds

Provide us with your personal information

Complete Name:

Complete Address:

Email:

Phone / Mobile Number:

Age:

Male Female Rather not say

That's about it! Stay healthy!

We will assess your information and will let you know soon if you need to get tested for COVID-19.

Click on the submit button to continue.

Success! We'll get back to you ASAP!

Meanwhile, clean your hands often, use soap and water, or an alcohol-based hand rub, maintain a safe distance from anyone who is coughing or sneezing and always wear a mask when physical distancing is not possible.

Go back from the beginning ➜