Visitors Health Declaration
1. Have you recently had or been a carrier of: -
o A food borne disease
Yes
No
o Typhoid or paratyphoid
Yes
No
o Tuberculosis
Yes
No
o Parasitic infections
Yes
No
2.Has any close family contact suffered from any of the above recently?
Yes
No
3. At present are you suffering from any of the following: -
o Diarrhea or vomiting
Yes
No
o Skin trouble
Yes
No
o Boils, sties or septic fingers
Yes
No
o Discharge from the ears, eyes, gums or mouth
Yes
No
Please give details of any other medical problems (for example recurring Gastrointestinal disorder.) Which may affect the food products during your visit?
4. Have you been abroad recently?
Yes
No
I declare that all the foregoing statements are true and complete to the best of my knowledge and belief.
Signature:
Submit