Home formulieren nl COVID-19 call back form COVID-19 call back form IF YOU HAVE CURRENT SYMPTOMS OF A POSSIBLE COVID-19 INFECTION YOU MUST CONTACT THE GGD FOR TESTING: CALL 0800-1202 Last name Initials Male/Female Male Female Date of Birth Are you short of breath? no yes Do you suffer from either Diabetes, Astma/COPD, Heart condition, or high bloodpressure? no yes Have you been traveling abroad in the last 2 weeks? yes no If yes, which country/countries? I have a fever higher than 38 C/100.4 F no yes Do you show any upper airway symptoms like coughing, runny nose, throat pain: please elaborate when did your first symptoms start My main concern is: e-mail address Please call me back on telephone number: To your knowledge, have you been in contact with a person with a proven COVID-19 infection in the last 2 weeks?