Date of filling: 21.12.2024 21:46:17 (appears automatically)
Clinic of planned treatment Kokshetau, Auelbekova Street 129/20 Uralsk, Ikhanova Street 52 Atyrau, Kulmanova Street 1 (Grand Atyrau Residential District) Ust-Kamenogorsk, Nursultan Nazarbayeva Ave. 29/23 Almaty, Kabanbai Batyra Street 122A Almaty, Rozybakiyeva Street, 105 B Almaty, Sholokhova Street 15 Nur-Sultan, Saraishyk Street 5, VP11 Nur-Sultan, Abay Ave. 28 Nur-Sultan, Kazhymukana Street 12
1. Have you and your child been in isolation or self-isolation for the last 14 days before visiting the clinic? Yes No
2. Were there any close contacts over the past 14 days with a person under the supervision due to COVID-19, who subsequently become ill? Yes No
3. Were there any close contacts over the past 14 days with a person who was diagnosed with a laboratory confirmed COVID-19? Yes No
4. Have you and your child visited a clinic or medical centre where patients are tested for COVID-19? Yes No
5. Have you and your child experienced one or more symptoms in the last 14 days?
increased body temperature over 37.5C
cough (dry or with a small amount of sputum)
shortness of breath
fatigue
feeling of stuffiness in the chest
myalgia - muscle pain
I and my child experienced none of the symptoms listed above
6. Have you tested for COVID-19? Yes No
+ -
I understand that the provision of false information is a violation of the law in sanitary and epidemiological welfare of the population and it entails corresponding responsibility.
