SYMPTOMS FORM

PERSONAL DATA

First Name *
Mid Name
First Last Name *
Second Last Name *
Document type (Country ID, Passport ID) *
Document ID *
Sex (male, female, other)
Age *
Number of family members at home
Nickname * // (Same for all applications)

I RESPONSIBLY DECLARE THAT as by (date)*

I have no symptoms
I have fever
I have cough and breathing issues
I have fever, cough, annd breathing issues (Choose one)

LOCATION

Geolocation * // (It will only be taken up to the second decimal of longitud and latitud, which is approximately equivalent to 1.1 km)