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Clinic Schedule
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Health Screening Packages
Pre-University Screening Package
Pre-Employment Screening Package
Peka B40
PERKESO (Program Saringan Kesihatan)
Umrah / Haji Vaccination Package
Vaccination Package
Contact Us
CALL US
CALL US
Welcome
About
Menu Toggle
Our Panels
Services
Menu Toggle
Clinic Schedule
Health Screening
Menu Toggle
Health Screening Packages
Pre-University Screening Package
Pre-Employment Screening Package
Peka B40
PERKESO (Program Saringan Kesihatan)
Umrah / Haji Vaccination Package
Vaccination Package
Contact Us
Main Menu
Welcome
About
Menu Toggle
Our Panels
Services
Menu Toggle
Clinic Schedule
Health Screening
Menu Toggle
Health Screening Packages
Pre-University Screening Package
Pre-Employment Screening Package
Peka B40
PERKESO (Program Saringan Kesihatan)
Umrah / Haji Vaccination Package
Vaccination Package
Contact Us
Welcome
About
Menu Toggle
Our Panels
Services
Menu Toggle
Clinic Schedule
Health Screening
Menu Toggle
Health Screening Packages
Pre-University Screening Package
Pre-Employment Screening Package
Peka B40
PERKESO (Program Saringan Kesihatan)
Umrah / Haji Vaccination Package
Vaccination Package
Contact Us
CALL US
CALL US
Welcome
About
Menu Toggle
Our Panels
Services
Menu Toggle
Clinic Schedule
Health Screening
Menu Toggle
Health Screening Packages
Pre-University Screening Package
Pre-Employment Screening Package
Peka B40
PERKESO (Program Saringan Kesihatan)
Umrah / Haji Vaccination Package
Vaccination Package
Contact Us
Main Menu
Welcome
About
Menu Toggle
Our Panels
Services
Menu Toggle
Clinic Schedule
Health Screening
Menu Toggle
Health Screening Packages
Pre-University Screening Package
Pre-Employment Screening Package
Peka B40
PERKESO (Program Saringan Kesihatan)
Umrah / Haji Vaccination Package
Vaccination Package
Contact Us
Paxlovid Questionnaire
"
*
" indicates required fields
Full Name
*
First
NRIC / Passport No.
*
Phone No.
*
Email
*
Full Address
*
Please answer all questions below.
Are you Covid-19 positive?
*
Yes, RTK Positive
Yes, PCR Positive
No
Do you have any of the following symptoms?
*
Please tick where applicable
Fever
Runny / nasal congestion
Sore throat
Cough productive of phlegm
Fatigue / tiredness
Body aches
Stomach pain
Diarrhoea
Shortness of breath / difficulty in breathing
Chest pain
Lose sense of smell / taste
Do you have medical illness?
*
High blood pressure
Diabetes
Asthma / COPD
Heart Disease
Stroke
Cancer
Thyroid Disease
Seizures / Epilepsy
Allergies to medications
Allergies in general
Immunocompromised / or on long term steroid therapy / disease modifying drugs
Other
How old are you?
*
Below 17 years old
Between 18-59 years old
Above 60 years old
How many days has it been since you first had symptoms?
*
Are you pregnant / breastfeeding?
*
Yes
No
Do you have any kidney impairment ? Or on dialysis?
*
Yes
No
Do you have liver disease?
*
Yes
No
What is your weight (in KG)?
*
What is your height (in Meter)?
*
BMI (kg/m2)
Do you smoke?
*
Yes
No
Have you been vaccinated fully to Covid-19?
Yes, fully vaccinated with at least 1 booster
Yes, but only primary doses (1st dose and 2nd dose)
Not vaccinated
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