COVID19 Screening Form
To minimize the spread of COVID-19, history screening is required. Please answer the following questions prior to entering the hospital area. Thank you for your cooperation.
◉ First Name and Last Name
◉ Contact No.
◉ Do you have any of the below symptoms or history
(Select all that apply):
Having body temperature higher than 37.5°C
Dry cough or sneezing
Loss of taste/loss of appetite
Loss of smell
Do you live in
Samut Sakorn
Province in the last 14 days.
Have you or anyone in your household, travelled / returned from
Samut Sakorn
Province in the last 14 days.
Have you or anyone in your household, contacted with anyone who suspected Coronavirus (COVID-19) cases in the last 14 days.
None of the above
Providing incomplete or misleading information is deemed unlawful and is subject to legal punishment under Thailand's the Communicable Disease Art.
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