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Contact Tracing

This document appears to be a health screening form collecting an individual's name, residence, contact number, temperature, and answers to questions regarding COVID-19 symptoms, exposure history, and travel history. The questions ask whether the individual is experiencing symptoms like sore throat, body pains, or fever; has been in contact with confirmed COVID-19 patients; has been in contact with others exhibiting symptoms; and has a travel history within or outside of the country in the past two weeks. The individual must provide a date and signature at the bottom.

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Christel Jewel Cajes
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96 views1 page

Contact Tracing

This document appears to be a health screening form collecting an individual's name, residence, contact number, temperature, and answers to questions regarding COVID-19 symptoms, exposure history, and travel history. The questions ask whether the individual is experiencing symptoms like sore throat, body pains, or fever; has been in contact with confirmed COVID-19 patients; has been in contact with others exhibiting symptoms; and has a travel history within or outside of the country in the past two weeks. The individual must provide a date and signature at the bottom.

Uploaded by

Christel Jewel Cajes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Name: Sex:

Residence: Age:
Contact Number:
Body Temperature (as of today)
Yes No
1. Are you A. Sore throat (pananakit ng lalamunan/
experiencing masakit lumonok)
(nakakaranas ka ba
ng:?) B. Body pains (pananakit ng katawan)
C. Head ache (pananakit ng ulo)
D. Fever for past few days (lagnat sa
nakalipas na araw)
2. Have you worked together or stayed in the same close
environment with a confirmed COVID-19 patient?
(May nakasama ka ba o nakatrabahong tao na
kumpirmadong may COVID-19 or may implikasyon ng
coronavirus?)

3. Have you had a direct contact with a person having fever,


colds, cough and sore throat for the past two (2) weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon, at
pananakit ng lalamunan sa nakalipas na dalawang linggo?)

4. Do you have a travel history anywhere in NCR ? If yes,


where? (Ikaw ba ay nakapagbyahe sa
ibang parte ng NCR? Kung oo, saan? )

5. Do you have a travel history outside the Philippines for the


last fourteen (14) days? If yes, where?
(Ikaw ba ay nakapagbyahe
galing sa ibang bansa sa nakalipas na dalawang linggo? Kung
oo, saan? )

Date and Signature:

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