Patient Under Investigation PUI

Are you experiencing the following respiratory conditions with Signs and Symptoms *

History during 14 days before screening *

No history of travel abroad

Departure to/from or stay at pandemic COVID-19 high risk areas

Work to any authorized ASQ practitioner

Work with tourist , crowded areas or contact with many people

Closed contact with confirmed corona virus 2019 patients or confirmed case's secretion

Stayed/visited in communities or areas with many people such as ( department store, hospital, public transport, Gambling den, Karaoke room, Pub, Boxing stadium) where found case COVID19 confirmed within 1 month.

List of Countries you visited before arriving in Thailand

Date of Arrival in Thailand

What's the name of the hotel you stayed in ?

What is your job occupation/s in your Country and where it is located?

What is your relationship with confirmed case's Covid-19 patient/s ?

Please specify the complete Name/Address/location of the place last visited

All information's given and stated above is reliable and true.

I'am : *

Patient

Patient's guardian

What's your relationship with the patient/s?

Patient's signature / Guardian's signature *

Clear

If you are human, leave this field blank.

Covid-19 instructions

Patient Under Investigation PUI