Form of address*
Title
Name*
First name*
Sex*
Date of birth*
Profession*
Land
Street*
House number*
Postal code*
City*
Phone*
Mobil*
E-mail address*
Details of place of work/residence (please tick if applicable):
Type
I work in an open-plan office (=more than 2 employees in the office)
Department
Street
House number
Postal code
City
Phone
Mobil
E-mail adress
I have been on sick leave since:
Date of the last visit:
I have the following underlying diseases (e.g. cancer, diabetes, ...):
I am currently or have recently been hospitalized in connection with a positive corona test
Hospital
Hospital admission (date)
Hospital discharge (date)
Date of first symptoms
Current state of health
Expression of the symptoms
Fever
last measured temperature
(degrees Celsius)
Coughing
Exhaustion
Breathing problems
Chills
Sore throat
Headache and aching limbs
Blocked nose
Nausea
Vomiting
Diarrhea
Loss of smell/taste
Others
Remarks
Date of the test*
Type of test*
Result
Test reason*
First vaccination (Date)
Vaccine
Second vaccination (Date)
Third vaccination (Date)
contact persons*
Ich versichere, dass meine vorstehenden Angaben wahr und richtig sind.
Type of contact*
Date of contact:
Form of address
Titel
E-mail address
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