Анкета

Language:

Method of sample collection:

Drive-thru - Halyk Arena

Walk-thru - Nurly Tau

Drive-thru - Mall Aport

E-mail address

Phone (+код страны) номер

Name

Surname

Middlename

Date of birth

ID (IIN)

Address

Place of work

Gender

Male

Female

Have you traveled abroad for the past 14 days?

Yes

No

Have you had contact with a COVID-19 patient in the past 14 days?

Yes

No

Please mark the relevant symptoms.

If you have other symtoms, what exactly it is?

Have you had pneumonia recently (within 3 months), or have you had it in the past?

No

I recently had pneumonia (within 3 months)

I was sick in the past

Please check if you have any of the following medical conditions

If you have the others, what exactly it is?

Have you been hospitalized within a month?

Yes

No