Health Declaration Form Thailand

Personal Information

Passport Number

Email

Given name (English)

Middle name (English)

Family name (English)

Reporting Reason

Symptoms

Please mark the following symptoms listed you have had in past two weeks. (select more than one is accepted.)

Diarrhea

Vomiting

Abdominal pain

Fever

Rash

Headache

Sore throat

Jaundice

Cough or shortness of breath

Enlarged lymph glands or tender lumps

No symptom

Other (Specify)

Departure from country / area

Date of Arrival

Contact Address In Thailand

Contact Number In Thailand

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