HEALTH DECLARATION HEALTH DECLARATION

Due to the recent worldwide outbreak of COVID-19, Due to the recent worldwide outbreak of COVID-19,
St. Luke's Medical Center Extension Clinic would like to St. Luke's Medical Center Extension Clinic would like to
ensure that our patients/customers and employees ensure that our patients/customers and employees
are safe from exposure to the disease. In line with this, are safe from exposure to the disease. In line with this,
we are requesting all patients, including companions we are requesting all patients, including companions
and visitors, to complete this form. and visitors, to complete this form.

The data that you provide is strictly confidential and used for hospital reference only. The data that you provide is strictly confidential and used for hospital reference only.

Name: _________________________ Age:____ Sex:____ Contact No.: ____________ Name: _________________________ Age:____ Sex:____ Contact No.: ____________
I am a [ ] Patient [ ] Visitor [ ] Companion [ ] Others___________ I am a [ ] Patient [ ] Visitor [ ] Companion [ ] Others___________

Please tick an answer for every question item NO YES Please tick an answer for every question item NO YES
Have you been tested for COVID-19 in the last 2 weeks? Have you been tested for COVID-19 in the last 2 weeks?
Date swabbed: Result (if available): Date swabbed: Result (if available):
Have you been evaluated as Probable or Suspected for COVID-19? Have you been evaluated as Probable or Suspected for COVID-19?
If YES, when did your quarantine start? If YES, when did your quarantine start?
Did you have any travel history in the past 14 days? Did you have any travel history in the past 14 days?
If YES, when and where? If YES, when and where?
Did you come in close contact or are you staying in the same close Did you come in close contact or are you staying in the same close
environment with someone who is a confirmed COVID-19 case? environment with someone who is a confirmed COVID-19 case?
[ ] Relative [ ] Workplace [ ] Household When: _____________ [ ] Relative [ ] Workplace [ ] Household When: _____________
Have you experienced any of the following symptoms in the Date Have you experienced any of the following symptoms in the Date
NO YES NO YES
last two weeks? Experienced last two weeks? Experienced
Fever (>38°C) Fever (>38°C)
Diarrhea, Nausea, or Vomiting Diarrhea, Nausea, or Vomiting
Shortness of breath or other respiratory symptoms Shortness of breath or other respiratory symptoms
Other respiratory symptoms: Other respiratory symptoms:
Headache Headache
Joint Pain or Muscle Pain Joint Pain or Muscle Pain
Flu-like symptoms such as: Flu-like symptoms such as:
Chills or repeated shaking with chills Chills or repeated shaking with chills
Body aches Body aches
Sore throat Sore throat
Runny Nose or Sneezing Runny Nose or Sneezing
Cough and colds Cough and colds
Loss of smell and/or taste Loss of smell and/or taste
Eye discharge Eye discharge
Skin rash or discoloration of toes/fingers Skin rash or discoloration of toes/fingers
Loss of speech or movement Loss of speech or movement

I agree that the information provided in this document is true and correct to the best of my I agree that the information provided in this document is true and correct to the best of my
knowledge and understand that any dishonest answers may have serious legal and public knowledge and understand that any dishonest answers may have serious legal and public
health implications under RA 11332. health implications under RA 11332.

I declare that all information disclosed above is TRUE and CORRECT. I declare that all information disclosed above is TRUE and CORRECT.

Signature: __________________________________ Date:_______________________ Signature: __________________________________ Date:_______________________

Approved entry by: ___________________________ Referred to:__________________ Approved entry by: ___________________________ Referred to:__________________
(Name & signature of associate) (Name & signature of associate)