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Country(ies) visited on the last 14 days starting from the latest.
Purpose of visit
Have you had close contact with sick person(s) (persons with fever, cough and difficulty in breathing) in the past 14 days ?

Please tick if you have any of the underlisted signs and symptoms.
Fever

Cough

Headache

Bodily Weakness

Sore throat

Sneezing

Runny nose

Others
Vaccination status

Number of doses
Date of first dose
Date of second dose
Please tick to consent to the information provided.