1. In the last 14 days, have you travelled internationally?

   Yes No
2. In the last 14 days, have you been in physical contact with someone who tested positive for COVID-19?

   Yes No
3. Are you currently suffering from any of the following symptoms?

   Yes No
   Fever Yes No

   Cough Yes No

   Sore Throat Yes No

   Shortness of Breath Yes No

   Body Pains / Headache Yes No

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