Date *

MM

DD

YYYY

Name *

First Name

Last Name

Have you been diagnosed with COVID-19 over the past two weeks? *

Yes

No

Are you a probable COVID-19 case? *

Yes

No

Are you required to self-isolate &/or waiting for COVID-19 test results? *

Yes

No

Do you have any of the following symptoms? *

New or worsening cough

Sneezing or runny nose

Sore throat

Fever

Fatigue

Shortness of breath

Loss of taste or smell

None of the the above

Do you have any of the following symptoms without any other contributing diagnosis? *

Muscle aches

Vomiting

Malaise

Chest pain

Abdominal pain

Joint pain

Confusion / Irritability

None of the above

If you answered YES to any of the above symptoms, have you:

Had close contact with someone who is a probable or confirmed COVID-19 case

Been at a current location of interest

Traveled internationally

Had direct contact with someone who has travelled overseas

Exited a MIQ facility

Travelled from a region outside of Auckland

None of the above