Register for CSO Wellness Programme
Status
Would you like to join the COVID-19 Wellness Monitoring Programme?
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Yes
No
Which Shul do you belong to?
Have you attended Shul, School, or a Charity Organization in the last 7 days?
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Yes
No
Please specify which one?
Have you been tested for COVID-19?
-- Select --
Yes
No
Are you Covid Positive?
-- Select --
Yes
No
Awaiting Results
COVID Confirmed Date (Date cannot be older than 2 months)
Day Start of Symptoms (Date cannot be older than 2 months)
When was your test done? (Date cannot be older than 2 months)
Why are you Signing Up?
Basic Info
Name
Surname
Email
Gender
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Male
Female
Other
Age
Contact Number
Notes and Other Information
Contact Details
Unit Number
Complex/Building Name
Search Address
Address
Suburb
GP Name
GP Contact Number
Next of Kin Name
Next of Kin Surname
Next of Kin Contact Number
Next of Kin Relationship
Medical Conditions
Do you have Hypertension?
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Yes
No
Do you have COPD?
-- Select --
Yes
No
Do you have Asthma?
-- Select --
Yes
No
Are you HIV Positive?
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Yes
No
Do you have an Auto Immune Disease?
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Yes
No
Do you take Chronic Steroids?
-- Select --
Yes
No
Do you have Diabetes?
-- Select --
Yes
No
Are you Obese?
-- Select --
Yes
No
Do you have any Cardiovascular Disease?
-- Select --
Yes
No
Do you have Renal Disease?
-- Select --
Yes
No
Do you have Inflammatory Bowel Disease?
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Yes
No
Do you have Dementia?
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Yes
No
Do you have Cancer?
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Yes
No
If Female, are you Pregnant?
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Yes
No
Do you have any Solid Organ Transplants?
-- Select --
Yes
No
By completing this form, I am giving permission to CSO Cape Town to contact me on a regular basis during my isolation period.I agree to co-operate with the assigned volunteer and will provide said volunteer with any medical information that they require.
I acknowledge and agree that CSO Cape Town reserves the right to remove me from the programme should I be found not to be adhering to the regulations and / guidelines as prescribed, from time to time, by the National Institute of Communicable Diseases(NICD) or otherwise for good reason, as determined in CSO Cape Town’s reasonable discretion.
Register
