4th Avenue Coffee Roasters Illovo COVID-19 Questionnaire

First Name and Surname *

Contact Number *

Please Enter Your Temperature *

Residential Area (ie. Bryanston / Illovo) *

Have you experienced flu-like symptoms? Anything including a high fever, shortness of breath, sore throat/cough, tiredness, muscle pain, diarrhoea or any other digestive upset, loss of sense of smell or taste or any new skin conditions on toes and/or fingers. *

Yes

No

Have you tested positive for COVID-19 within the last 14 days? *

Yes

No

Have you been in contact with anyone who has tested positive for COVID-19 within the last 14 days? (Work or social) *

Yes

No