Epidemiological questionnaire
The answers to the questions about trips abroad are assessed taking into account the weekly list of risky countries provided by the Ministry of Health of the Republic of Lithuania. If any answers to the questionnaire changes, we ask you to contact the Clinic's front desk before the visit.
Questions for COVID-19 risk assessment |
Mark the answer |
Have you been abroad in the last 14 days? |
Yes / No |
Have you been in contact with a person who has traveled abroad in the last 14 days? |
Yes / No |
In the last 14 days, have you been in contact with a person who has been diagnosed with COVID-19? |
Yes / No |
In the last 14 days, have you been in contact with people who are in self-isolation? |
Yes / No |
Do you currently have a fever or had a fever in the last 14 days? |
Yes / No |
In the last 14 days, have you experienced any breathing-related troubles (e.g. cough, shortness of breath, difficulty breathing) or suffered from tiredness and loss of appetite? |
Yes / No |
In recent days have you experience a sudden loss of smell and/or taste? |
Yes / No |
In the last 14 days, have you been in contact with 2 or more people who have a fever and/or breathing problems (e.g., sneezing, coughing, choking)? |
Yes / No |
Has a molecular SARS-CoV-2 test been performed? If so, what was the result? When was it performed? |
Yes / No Negative / Positive |
Have you had COVID-19? |
Yes / No |
Are you taking any anti-inflammatory drugs? If so, for what reason and when was the last time you took it? |
Yes / No |
Let's protect each other!