Qatargas Medical Department

Post - Traveler’s Questionnaire

Disclaimer: This questionnaire is intended for the use of Qatargas Medical Department only. The information
contained herein shall be treated as confidential.

Instruction: Please answer the questions as required.

1. Have you been in other countries recently? (Within 14 days) YES ___ NO
If YES what countries?

2. Have you had any connecting flights or stop overs in your itinerary? YES ____ NO
If YES what countries?

Dates of Travel
Countries Regions/Cities/Towns
From To

3. Have you had recent contact with suspected/confirmed case for COVID-19? ____ YES _____ NO
If YES, WHEN_______________________, WHERE______________________

4. Have you had recent contact with a recent traveler arriving from endemic area? ____ YES _____ NO
If YES, WHEN_____________, FOR HOW LONG______________, ARRIVING FROM WHERE _______________

5. Have you suffered from any symptoms below? YES NO

If YES, please tick the applicable boxes.

Fever Diarrhea Weakness

Severe Headache Vomiting Difficulty of breathing
Muscle Pain Abdominal Pain/Chest Pain Cough
Weakness Lack of Appetite Skin Rashes
Conjunctivitis Bleeding, if yes please specify:

Note: if you have any of the following symptoms, please go to any health facility near your area.

I hereby confirm that the information I have provided are correct.

Staff Number: Company:

Name: Qatar ID:
Signature: Date:

Doc: 03-07-34-196 Traveller's

QuestionnaireRev: 14/01/2016 1:25
PMLSB: JF