RP-App

• Conducted on

  Date

• Prepared by

• Name Surname

• Contact Number

• Vehicle Reg

• Reason for entry

• Rynpark Unit Number

• Here to see?

• From?

Do you have any of the following COVID-19 symptoms?

• Fever

  Yes

  No

• Dry cough

  Yes

  No

• Tiredness (Fatigue)

  Yes

  No

• Difficulty breathing or shortness of breath

  Yes

  No

• Sputum production

  Yes

  No

• Chest pain or pressure

  Yes

  No

• Body ache and pains

  Yes

  No

• Myalgia or arthralgia (Muscle or joint pain)

  Yes

  No

• Sore throat

  Yes

  No

• Headache

  Yes

  No

• Chills

  Yes

  No

• Gastrointestinal symptoms such as nausea, vomiting or<br>Diarrhoea<br>

  Yes

  No

• Anosmia (loss of sense of smell) and dysgeusia (alteration of the sense of taste)

  Yes

  No

• Do you have any chronic respiratory illness, example Asthma, Emphysema, COPD?

  Yes

  No

• Have you been in contact with somebody that could be infected?

  Yes

  No

• Have you been to a Hospital in the last 2 weeks, if Yes please provide information

  Yes

  No

• Have you been to a Funeral in the last 2 weeks, if Yes please provide information

  Yes

  No
Temp Reading 1 Temp Reading 2

• Reported abnormalities / high temperature to

  Nurse 1

  Nurse 2

  Nurse 3