Formulir Skrining COVID-19 RS St. Carolus

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Mohon diisi dengan jujur sesuai keadaan dan gejala Anda saat ini (Please fill the form honestly, based on your current condition)

Nama Lengkap sesuai identitas *

Full Name (as written in Valid ID (KITAS/Passport)

Tanggal Lahir *

Date of Birth

YYYY

Apakah anda Demam? *

Any Fever?

Tidak

Batuk? *

Any Cough?

Tidak

Pilek? *

Flu or runny nose?

TIdak

Sakit tenggorokan? *

Sore throat?

Tidak

Sakit kepala? *

Headache?

Tidak

Letih, Lemas, Lesu? *

Fatigue, Malaise?

Tidak

Nyeri Otot? *

Muscle Pain?

Tidak

Sesak? *

Shortness of breath

Tidak

Mata merah? *

Eye redness?

Tidak

Kontak dengan pasien COVID-19 Positif *

Any contact with COVID-19 patients?

Tidak

Perjalanan ke luar DKI Jakarta (Zona Merah/Kuning) dalam 14 hari terakhir *

Any travel to other city than DKI Jakarta (Red/Yellow zone) within 14 days?

Tidak

Perjalanan ke luar negri *

Any travel to or from other country within 14 days?

Tidak

Apakah Anda sudah pernah screening Rapid Test Antibodi COVID-19 *

Have you ever been tested for Rapid COVID-19 Antibody?

Tidak

Apakah Anda sudah pernah skrining Swab PCR COVID-19 *

Have you ever been tested for PCR Swab COVID-19?

Tidak

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms