COVID-19 Medical Questionnaire Step 1 of 21 4% Entreprise identification number* Identification* First Last Adresse* City State / Province / Region Q01.0: In the last 14 days. Did you took the plane?* Yes No Q01.1 Flight Date * DD slash MM slash YYYY Q02.0: Have you been closely in contact with someone that might have or that have been diagnosed with COVID-19? * Yes No Q02.1 Date of the last contact * DD slash MM slash YYYY Q03.0: In the last 14 days. Did someone living at the same adress then you have shown symptoms of fiever, cough, shortness of breath * Yes No Q03.1 Date of the first symptom observed* DD slash MM slash YYYY Q03.2 Date of the end of the symptoms observed by the individual DD slash MM slash YYYY Q04.0 In which age group are you?* 70 years and over 60 to 69 years old Less then 60 years old Q05.0: How tall are you?* Q06.0 What is you weight?* Q07.0 Do you have a lung disease?* Yes No Q07.1 Clarifications * Q08.0 Do you smoke?* Yes No Q08.1 Do you cough frequently?* Q09.0: Do you have asthma?* Yes No Q09.1 Clarifications* Q10.0 Are you immunosupressed or dou you take immunospresive drugs?* Yes No Q10.1 Precision* Q11.0 Do you have a heart disease ( heart problems, stroke)* Yes No Q10.1 Clarifications* Q12.0 Do you suffer from high blood pressure * No Yes, I don't take any drug, i control the disease with foods Yes, I take only one type of drug to control the disease Yes, i take drugs to control the disease Q13.0 Do you have a current or recent cancer?* Yes No Q14.0 Do you have a chronic renale disease?* Yes No Q15.0 Do you have a hepatic insufficiency?* Yes No Q16.1 In the last 14 days. Did you got or did you have fiever?* Yes No Q16.1 Date when the first symptom was observed* DD slash MM slash YYYY Q16.2 End date of the last symptom observed DD slash MM slash YYYY Q17.0 Since the beggining of march . Did you had one of the following symptoms ?* No Cough (except smoker ) Expectorations (sputum) except smoker Sore throat Q17.1 Date when the first symptom was observed* DD slash MM slash YYYY Q17.2 End date of the last symptom observe DD slash MM slash YYYY Q18.1 In the last 14 days did you had?* No Breathing difficulty Chest pain Shortness of breath Difficulty to lay down because og breathing difficulty Q18.1 Date when the first symptom was observe* DD slash MM slash YYYY Q18.2 End date of the last symptom DD slash MM slash YYYY Q19.0 Since the begining of march did you have flu symptoms , if so which?* No Decreased appetite Muscle pain, abnormal fatigue Congestion Headaches Nausea, vomiting Diarrhea Q19.1 Date when the first symptom was observe* DD slash MM slash YYYY Q19.2 End date of last symptoms DD slash MM slash YYYY Q20.0 Since the beginning of March, did you had symptoms of anosmia (lost of taste and/or smell ) Yes No Q20.1 Day when the first symptom was observe* DD slash MM slash YYYY Q20.0 Day when last symptoms where observe DD slash MM slash YYYY Q21.0 Since the beggining of March did you have the following symptoms ?* No To be confused Lost of consciousness Q21.1 Date of the first symptoms observe?* DD slash MM slash YYYY Q21.2 Symptoms end date ? DD slash MM slash YYYY Consent By signing, I authorize the Medical Clinic to share with the Requester the report based on my answers and indications, including the conclusions, as well as all the information about my state of health. I acknowledge that my answers will serve to identify my state of health in connection with the COVID-19, as of today and a risk assessment of contagion will be carried out according to the guidelines of the Public Health. I acknowledge that giving false or misleading information could cause the Claimant to take action. Signature* Δ