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 last 21 days, which regions/ countries/ territories have you traveled to (may travel across multiple places)  
Have you noticed any of the following signs in the last 21 days? (*)
Symptoms Yes No
Fever (*)
Cough (*)
Shortness of breath (*)
Pneumonia (*)
Sore throat (*)
Tired (*)
During the past 21 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 (*)