Health Check Form | 宝島旅

Please fill out this form to prevent spreading of Covid-19. Please fill in theinformation for every participant and send the information before the activity.

If someone of you has fever of 37.5°C or more or if you have symptoms aswritten in questions 1-5, the person cannot participate to the tour.

※Please avoid eating or spending time with many people, talking without amask etc. doing things or visiting places that may make the virus spread.

【Participant 1】
Name
Age	years
Body temperature	℃
Question 1	Do you have any of the following symptoms (1-5)? (1)A fever of 37.5°C or over withing the past two weeks. (2)Cough. (3)A sore throat. (4)A loss or change to your usual sense of taste. (5)A loss or change to your usual sense of smell.
Question 2	Have you been overseas within the past 14 days? Have you been in contactwith a close contact of a person with Covid-19 or someone who is suspected ofhaving Covid-19?
【Participant 2】
Name
Age	years
Body temperature	℃
Question 1	Do you have any of the following symptoms (1-5)? (1)A fever of 37.5°C or over withing the past two weeks. (2)Cough. (3)A sore throat. (4)A loss or change to your usual sense of taste. (5)A loss or change to your usual sense of smell.
Question 2	Have you been overseas within the past 14 days? Have you been in contactwith a close contact of a person with Covid-19 or someone who is suspected ofhaving Covid-19?
【Participant 3】
Name
Age	years
Body temperature	℃
Question 1	Do you have any of the following symptoms (1-5)? (1)A fever of 37.5°C or over withing the past two weeks. (2)Cough. (3)A sore throat. (4)A loss or change to your usual sense of taste. (5)A loss or change to your usual sense of smell.
Question 2	Have you been overseas within the past 14 days? Have you been in contactwith a close contact of a person with Covid-19 or someone who is suspected ofhaving Covid-19?
【Participant 4】
Name
Age	years
Body temperature	℃
Question 1	Do you have any of the following symptoms (1-5)? (1)A fever of 37.5°C or over withing the past two weeks. (2)Cough. (3)A sore throat. (4)A loss or change to your usual sense of taste. (5)A loss or change to your usual sense of smell.
Question 2	Have you been overseas within the past 14 days? Have you been in contactwith a close contact of a person with Covid-19 or someone who is suspected ofhaving Covid-19?
【Participant 5】
Name
Age	years
Body temperature	℃
Question 1	Do you have any of the following symptoms (1-5)? (1)A fever of 37.5°C or over withing the past two weeks. (2)Cough. (3)A sore throat. (4)A loss or change to your usual sense of taste. (5)A loss or change to your usual sense of smell.
Question 2	Have you been overseas within the past 14 days? Have you been in contactwith a close contact of a person with Covid-19 or someone who is suspected ofhaving Covid-19?
【Participant 6】
Name
Age	years
Body temperature	℃
Question 1	Do you have any of the following symptoms (1-5)? (1)A fever of 37.5°C or over withing the past two weeks. (2)Cough. (3)A sore throat. (4)A loss or change to your usual sense of taste. (5)A loss or change to your usual sense of smell.
Question 2	Have you been overseas within the past 14 days? Have you been in contactwith a close contact of a person with Covid-19 or someone who is suspected ofhaving Covid-19?