Uganda Ministry of Health

International Arrivals Health Form

Traveler's Name	Country of Embarkment	Point of Entry

Date of Arrival	Age	Sex

Passport Number	Airport of Embarkment	Flight Number

Countries visited in the last 14 days	Physical Address	Planned Duration of Stay in Uganda (days)

Phone Number	Next of Kin Phone Number	Countries Visited

In the last 21 days have you been/travelled to a country or contact with a person suffering from Ebola? Yes No	If yes, name the countries
Have You Been To China Yes No	Have You Been to any country (ies) affected by Corona Virus in the past two weeks? Yes No
Do you have any of the following signs and symptoms?
Fever Yes No	Headache Yes No	Cough Yes No
Sore Throat Yes No		General Body Weakness (Fatique) Yes No
Dificulty Breathing Yes No	Diarrhoea Yes No	Vomiting Yes No
Blood in cough or blood or stool Yes No	Abdominal Pain Yes No	Bleeding from Body Parts Yes No
During the last 21 days, have you been in contact with a suspected or confirmed Ebola patient in the last 3 weeks Yes No	During the last 21 days, have you participated in the burial of a person suspected to have died of Ebola Yes No