Suisse Clinic Covid19 test form

Enter Your First Name

Enter Your Last Name

Select your Gender

Male Female

Enter Your Age

Select Your Nationality

Enter Your residence (optional)

choose Your subcity

Enter woreda (optional)

Enter Kebele (optional)

Enter House number (optional)

GPs (for house collection) optional

Enter your phone number

Enter alternate phone number

Enter your email

Enter Passport number (if you are a traveller)

Occupation

Health care worker
Driver
Government Employee
Self Employed
Others

If your occupation isn't listed above type it here , or you can skip

Enter Your occupational region (optional)

Enter Occupational sub-city Select unknown to skip

Occupational Woreda (optional)

Where do you work

Do you show any symptom compatible with COVID-19?

Yes No

If Yes, Do you have any of these symptom?

Cough
Fever
Shortness of breath
Sore throat
Headache
Easy fatigue

If you Show a symptom Can you specify Date of symptom on set , if not skip

Do you have any chronic disease/s?

Yes No

If yes, can you list your chronic disease/s? select 'none' if no

Diabetes Mellitus
Hyper Tension
HIV
Chronic Respiratory Disease
Chronic Cardiac disease
Pregnant
Other

Do you have a chronic disease/s that is not on the list? skip if none

Have you had a contact with a confirmed covid-19 case?

Yes No

If you have a contact please check from the list

House-hold
Work-place
Other

Do you have a contact case not on the list? skip if none

Have you had a recent history of travel to area/s where there is a community transmision?

Yes No

If you have a travel history please list country/ies, or skip if none

City/towns/province, or skip if none

Return Date , or skip if none

Reason for testing When would you like to take the test?