Dear Sir / Madam,
It is important that we prevent the spread of COVID-19 together. To assess whether it is responsible to treat you, we ask you to answer the questions below before entering the treatment. Please fill in your name and date and sign the form.
Name: ____________________
Yes/No
1. Have you had a confirmed corona infection?
2. Do you think you have had a corona infection?
3. If you answered yes to question 1 or 2: have you been free of complaints for more than 24 hours?
4. Have you been in contact with a COVID-19 patient?
5. If you answered yes to question 4: was that more than 14 days ago?
6. Have you had any of the following symptoms now or within the past 24 hours:
– (nose) colds such as coughing, coughing or sneezing, runny nose or sore throat
– loss of smell and / or taste
– fever (38 degrees or higher)
– burning eyes
– tiredness
– headache
– feeling sick and / or diarrhea
– shortness of breath
7. Do you have roommates / family members who have or had fever or shortness of breath now or less than 14 days ago?
If you answer one of the above questions with yes, please contact Ping (06 45 79 80 84) or Taco (06 333 120 73).
If you answer questions 6 and 7 with yes, we cannot treat you and ask you to stay at home / to go directly home / According to the RIVM guidelines you must stay in home isolation / According to the RIVM guidelines you should consult your doctor (by telephone).
Date signature: _______________________