ASQ : EN New Patient registration

---Covid-19 Screening assessment---

Arrival Time *
Do you experience any of the following respiratory conditions in the last 14 days?
Do you have a history of fever detected? *
Have you been confirmed COVID-19 infected? *
How are they treated? *
What is your medical history? *
How is your diabetes control? *
Do you need dialysis? *
Do you smoke? *
Do you drink alcohol? *
Do you currently taking any medicine? *
Do you need to take sleeping pill? *
For social security : Would you like us refer you to contracted hospital ?
COVID-19 Screening consent *
Please attach file for the COVID-19 test report
Maximum upload size: 6MB