ealth information to you ,please provide the name of a close personal contact or a work contact. This must NOT be you. Name Tel. No. РPlease describe the countries and cities (towns) where you stayed in the last 7 days: .РDid you have close contact patients of flu or with flu-like symptoms in the last 7 days? Yes□ No □РIf you have the following symptoms and diseases, please mark “√” in the corresponding “□”Р □Fever □Cough □Sore throat □Muscle and joint pain □Stuffy noseР □Headache□Diarrhoea □Vomiting □Runny nose□Breath difficulty□FatigueР □Other symptoms РI declare that all the information given in this form is true and correct. РSignature of passenger Date:_______________РTemperature (for quarantine official only):______________℃РSignature of quarantine official: _________________________
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