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COVID-19 Self Assessment Survey Template

This self-assessment form is to help determine whether you should visit a health care provider for further COVID-19 related assessment and testing

List of COVID-19 Self Assessment Survey Questions

The following questions are included in this COVID-19 Self Assessment Survey Template. 

  • Are you experiencing any of the following symptoms? Please tick the relevant one:
  • Are you experiencing any of the following symptoms?
  • Have you been outside of the country within the last 14 days?
  • Have you returned your town/city from other parts of the Country within the last 14 days?
  • In the last 14 days, have you —
  • Full Name
  • Email
  • Mobile Number
  • Gender

Create and send this COVID-19 Self Assessment Survey with Zonka Feedback

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