FACULTATEA DE MEDICINĂ ÎN LIMBA ENGLEZĂ

FACULTY OF MEDICINE IN ENGLISH

QUESTIONNAIRE FOR THE EPIDEM IO LO G ICAL SCREENING

No. QUESTION YES NO

1. Have you been in contact with people diagnosed with SARS-CoV-2 virus(COVID-19) in
the last 14 days?
2. Have you interacted in the last 14 days with people who have shown symptoms
associated with SARS-CoV-2 virus infection (COVID-19)?
3. Have you interacted in the last 14 days with people who have been in isolation/
quarantine imposed by the authorities?
4. Have you been required to be isolated or quarantined at home by the authorities in
the last 14 days?
5. Have you had any of the following symptoms in the last 14 days?
- fever
- cough
- difficulty in breathing
- chills
- muscle pain
- headache
- sore throat
- nausea, diarrhea, vomiting
- loss of taste or smell
6. Do you suffer of other acute/chronic diseases? (please detail)

7. Have you had a Covid 19 infection during the last 90 days?

8. Have you got at least one dose of the vaccine against SARS-CoV-22?
I took note of the fact that non-compliance with the measures regarding the prevention or control of
infectious diseases is sanctioned according to art. 352 of the Criminal Code and art. 34 lit. m) of the
Government Decision no. 857/2011 regarding the establishment and sanctioning of contraventions
to the norms in the field of public health, with the subsequent modifications and completions.
Name and surname:
Date:
Signature: BODY TEMPERATURE:

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