RSUP Dr. Kariadi

Name

Address

Birth Date

Pasport Number

Date

Phone Number

Do you have high temperature (feeling hot to touch on the chest or tummy) ?

Do you have sore throat ?

Do you have cough ?

Do you have complaints Shortness of breath / Shortness of breath / Heavy breathing ?

Have you visited the region in Indonesia which there are COVID 19 positif case, in the last 14 days ?
Leave the fields blank if not

Have you travelled outside Indonesia which there are COVID 19 positif case, in the last 14 days ?
Leave the fields blank if not

Have someone with a confirmed case of COVID 19 been in close contact with you?
Contact means :

1. living in the same house
2. face-to-face contact, for example, talking for more than a few minutes
3. being coughed on
4. being within 2 metres of the person for more than 15 minutes
5. contact with their body fluids