QUESTIONNAIRE FOR THE EVALUATION OF THE RISK OF COVID-19

DISEASE IN PATIENTS PRESENTING AT THE EMERGENCY DEP. /

FRONTDESK

No ..............
RECORD No .........
PRESENTATION DATE: ...... / ...... / 2020

PATIENT’S NAME,
SURNAME: ......................................................................

DATE OF BIRTH: ...................

Note: tick the appropriate answer or complete no. of days

1. Are you a citizen / resident in countries / areas* with extended

community transmission of COVID-19?
YES □ NO □
a. If yes, are you within the first 14 days of leaving the country /
area?
YES □ NO □

2. Have you traveled in the last 14 days in countries / areas * with

extended community transmission of COVID-19?
YES □ NO □

3. Have you participated in the last 14 days in Conferences / Meetings

with international participation or other activities including recreation
which involved crowds of people coming from affected areas?
YES □ NO □

4. Have you come into contact in the last 14 days with patients diagnosed
with COVID-19 or with suspected COVID-19 infection?
YES □ (Specify the number of days elapsed from contact until the
presentation: ...... days) NO □

5. Have you been in contact in the last 14 days with body fluids (eg,
blood, feces, urine, saliva, semen, etc.) from a patient diagnosed with
COVID-19 or suspected COVID-19 infection?
YES □ NO □

If the answer is YES to at least one of the five questions, please immediately
notify our staff! (Triage nurse / reception staff)

PACIENT SIGNATURE:.......................................
EVALUATING RESPONsible:......................................