Table 2.

Questions to be answered periodically by the patient.

Name:	Identifier:
Date of Birth:	Race:	Sex(M/F):
Questions to Be Answered:		Yes	No
Have you been abroad in the last month?
If yes, please, name the region where have you been.
If yes, for how long, in months, have you been abroad?
Have you had any risk contact with people affected by—or that might be affected of—COVID-19?
Have you suffered—or are you suffering now—of fever, dry cough, or fatigue?
Have you had—or do you have now—breathing difficulties or a shortness of breath feeling?
Have you been—or are you now—affected by loss of smell or taste, headache, or any other discomfort or pain?
Do you have an occupation that involves risk to the respiratory system—for example, participation in mining operations?
If yes, please, explain which occupation it is