Medical declaration for inland people

( COVID-19 EPIDEMIC PREVENTION )
Warning: Declaring false information is a violation of Vietnamese law and may be subject to criminal handling
Contact address in Vietnam
The building where you work
The company / department you are working in
In the past 14 days, did you visit any of the following locations? (If selecting Other, specify the content in the Other box.)
Have you noticed any of the following signs in the last 14 days? (*)
Symptoms Yes No
Fever (*)
Cough (*)
Shortness of breath (*)
Pneumonia (*)
Sore throat (*)
Tired (*)
During the past 14 days, you were in contact with (*)
Yes No
Sick or suspected person, infected with COVID-19 (*)
People from countries with COVID-19 disease (*)
People with manifestations (fever, cough, shortness of breath, pneumonia) (*)
Which of the following diseases do you currently have? (*)
Name of illness Yes No
Chronic liver disease (*)
Chronic blood disease (*)
Chronic lung disease (*)
Chronic kidney disease (*)
Heart-related diseaes (*)
High Blood Pressure (*)
Immunocompromised (*)
Transplant recipients, Mercury bone (*)
Diabetes (*)
Cancer (*)
Pregnant (*)