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CLINICAL SCREENING
CLINICAL SCREENING FORM FOR COVID19
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Last Name
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1. Do you or the patient have a cough?
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2. Do you or the patient have shortness of breath?
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3. Do you or the patient have a high fever (over 38 degrees)?
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4. Do you or your patient have a sore throat?
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5. In the last 14 days did you or the patient travel outside of the South African borders?
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6. In the last 14 days did you or the patient have close contact with another person who has a confirmed COVID-19 infection
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NO
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