HEALTH DECLARATION

YES

Are you feeling well today?

Do you have a respiratory infection?

Do you have a fever?

Do you have a new or worsening cough?

Do you have a sore throat?

Do you have difficulty breathing?

Do you have coryza - head cold e.g. runny nose, sneezing, post-natal drip?

Do you have anosmia - loss of sense of smell?

YES

COMMENTS

In the last 14 days have you had contact with anyone diagnosed with COVID-19?

Have you ever been diagnosed with COVID-19?
If Yes, comment date of diagnosis............

In the last 14days have you been in any country other than the Cook Islands?

In the last 14 days have you worked at an International Airport, Maritime Port or at a Quarantine or Managed Isolation Facility?

In the last 14 days have you worked on an international aircraft or shipping vessel?

1. Medical Information (Please Select YES or NO)