Corona-Diary
Personal details
I am a
patient
contact person
Patient number *
Last name *
First name *
Phone number *
E-mail address
Swab? *
planned
successfull
no
Intended date
Result (if known) *
negative
positive
unknown
Pre-existing conditions (fill in in German if possible)
Medical staff?
Yes
No
Quarantine until *
Other persons in the household ?
Notes on buffering
We recommend that you save the form temporarily after filling out this page.
The data will be saved on your computer as an HTML file.
You can then open this file again and again to fill in and send the daily symptom query.
save
continue
Tägliche Symptomabfrage
Date of notification *
No symptoms today?
yes
no
Temperature in the morning: °C
Respiratory distress *
yes
no
no longer existing
improvement
deterioration
Smell/taste loss *
yes
no
no longer existing
improvement
deterioration
Diarrhoea *
yes
no
Frequency/consistency
Aching limbs *
yes
no
no longer existing
improvement
deterioration
Sore throat *
yes
no
no longer existing
improvement
deterioration
Cough *
yes
no
no longer existing
improvement
deterioration
Type of cough *
productive
dry
Headaches *
yes
no
no longer existing
improvement
deterioration
Cold *
yes
no
no longer existing
improvement
deterioration
Shortness of breath *
yes
no
no longer existing
improvement
deterioration
occurs
breathe calmly
under pressure
Dizziness *
yes
no
no longer existing
improvement
deterioration
Body Temperature >38,0°C
yes
no
max. body temperature today
Other symptoms (fill in in German if possible)
I would like the public health department to contact me by phone
Reason (fill in in German if possible) *
back
send form
Do You Have Questions?
OZG-Stadt
OZG-Strasse 1, 12345 OZG-Stadt
Telefon: 089-12345
E-Mail: info@ozg-stadt.de
Impressum
Datenschutz