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Field is required!
Field is required!
Field is required!
Field is required!
1. Have you lived / visited in the last month areas / countries where there were people suffering from COVID-19 infection?
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2. Have you come into direct contact with people who, in the last month, have lived / visited areas / countries where there were people suffering from COVID-19?
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3. Have you been in contact in the last month with patients diagnosed with COVID-19 or with suspected COVID-19 infection?
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4. Have you been hospitalized in the last 30 days?
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5. Do you have a diagnosis of neoplasm / treatment with cytostatics or other medical conditions that lead to decreased immunity?
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6. Have you had one or more of the following symptoms in the last 30 days?
Fever
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Cough
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Headache
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Difficulty breathing
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Difficulty swallowing
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Fatigue installed without explanation
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7. Have you been recommended to stay isolated at home for the last 14 days?
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8. Have you been positively diagnosed with COVID 19 infection or have you been declared HEALED by COVID19?
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Consent
I hereby give my consent, in accordance with Regulation (EU) 679/2016 of the European Parliament and of the Council of 27.04.2016, on the protection of physical personal data regarding the processing of personal data and on their free movement.
I declare on my own responsibility that the data and information provided to the medical staff are real and correct.
Your signature (Patient or belonging)
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Va rugam semnati