CAT/OP/11
Annex
Self-evaluation questionnaire*
Name and surname:
Age:
Profession:
Date:
1.
Do you have a fever? Critical symptom.
yes ( ) no ( )
2.
Do you have a dry cough? Critical symptom.
yes ( ) no ( )
3.
Do you feel tired? Complementary symptom.
yes ( ) no ( )
4.
Does your body ache? Complementary symptom.
yes ( ) no ( )
5.
Do you have a stuffy nose? Important symptom.
yes ( ) no ( )
6.
Do you have a runny nose? Important symptom.
yes ( ) no ( )
7.
Do you have a sore throat? Important symptom.
yes ( ) no ( )
8.
Do you have diarrhoea, vomiting or nausea?
Complementary symptom.
yes ( ) no ( )
9.
Do you have trouble breathing? Critical symptom.
yes ( ) no ( )
10.
Do you recognize odours without problems? New indicator.
yes ( ) no ( )
11.
Did you respect the quarantine regulations?
Complementary symptom.
yes ( ) no ( )
12.
Have you had a fever during the past 15 days?
yes ( ) no ( )
13.
Have you been in contact with anyone with COVID-19
during the past 15 days?
yes ( ) no ( )
Have you been in contact with anyone suspected of having
COVID-19 during the past 15 days?
yes ( ) no ( )
15.
Have you visited a high-risk zone during the past 15 days?
yes ( ) no ( )
16.
Have you been abroad during the past 15 days?
yes ( ) no ( )
17.
Are you or have you been affected by any of the following risk factors?: diabetes,
chronic bronchitis, chronic asthma, myocardial infarction, arterial hypertension,
cirrhosis, cancer, transplants, use of corticosteroids, use of biological drugs for
treating rheumatoid arthritis, psoriasis, multiple sclerosis, inflammatory bowel
disease.
yes ( ) no ( )
18.
Are you pregnant?
19.
If yes, please specify:
14.
yes ( ) no ( )
Signature:
* Based on work done by the National Mechanism for the Prevention of Torture of Paraguay. See
“Propuesta metodológica: Trabajo de monitoreo frente a la emergencia sanitaria COVID-19”, April
2020 (in Spanish only). Available at www.mnp.gov.py/index.php/investigacion-social/2015-08-2304-10-11/Documentos-de-trabajo/Propuesta-Metodol%C3%B3gica-Trabajo-de-Monitoreo-frente-ala-Emergencia-Sanitaria-COVID-19/.
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