Please enable JavaScript in your browser to complete this form.1. Do you have any symptoms like fever, cough, sneezing, sore throat, fatigue, myalgia?YesNo2. Do you have difficulty in breathing? YesNo3. Have you travelled outside country in past 30 days? YesNoIf yes,mention countries 4. Have you travelled inside India to any other cities in past 15 days?YesNoIf yes, mention cities 5. Have you been exposed to a confirmed Covid-19 case or to suspicious patient in last two weeks? YesNo6. Have you visited any healthcare facility (Clinic / Hospital etc.) in past two weeks? YesNo7. Are you residing in a locality that has been notified by government as a COVID-19 containment Zone in last 21 days? YesNoSubmit Covid-19 Questionnaire