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Health Declaration Form 2

This health declaration form collects information from individuals to assess potential COVID-19 exposure and symptoms. It asks for the person's name, date, address, and contact details. It then has a series of yes or no questions regarding COVID-19 symptoms experienced in the last 14 days, contact with confirmed COVID-19 cases, caring for COVID-19 patients without protective equipment, and travel history within and outside of the Philippines and specific locations. The individual certifies the information is true and consents to the data privacy policy.

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shela marie a. gungon
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44 views

Health Declaration Form 2

This health declaration form collects information from individuals to assess potential COVID-19 exposure and symptoms. It asks for the person's name, date, address, and contact details. It then has a series of yes or no questions regarding COVID-19 symptoms experienced in the last 14 days, contact with confirmed COVID-19 cases, caring for COVID-19 patients without protective equipment, and travel history within and outside of the Philippines and specific locations. The individual certifies the information is true and consents to the data privacy policy.

Uploaded by

shela marie a. gungon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Health Declaration Form

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY) :


Time (Oras):
Complete Current Address (Kasalukuyang tirahan):

Mobile / Phone Number (Numero ng telepono):


Email Address:

Put a check mark (✔) on the appropriate column of your response. (Lagyan ng tsek sa angkop sa sagot.)
No
Yes (Oo)
(Hindi)
a. Fever (Lagnat)
1. Are you experiencing or b. Cough and/or colds (Ubo at/o Sipon)
did you have any of the c. Body pains (Pananakit ng katawan)
following in the last 14 d. Sore throat (Pananakit o pamamaga ng lalamunan)
days? (Ikaw ba ay may e. Fatigue/Tiredness (Pagkapagod)
nararanasan o f. Headache (Pananakit ng ulo)
nakaranas ng mga g. Diarrhea (Pagtatae)
sumusunod na sintomas h. Loss of taste or smell (Nawalan ng panlasa o pang-
sa nakaraang 14 na amoy
araw?) i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
2. Have you had face-to-face contact with a probable or confirmed COVID-19 case
within 1 meter and for more than 15 minutes for the past 14 days? (May
nakasalamuha ka ban a maaaring o kumpirmadong pasyente na may COVID-19
mula sa isang metrong ldistansya o mas malapit pa at tumagal ng mahigit 15
minuto sa nakalipas na 14 araw?)
3. Have you provided direct care for a patient with probable or confirmed COVID-19
case without using proper “Personal Protective Equipment (PPE)” for the past 14
days? (Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19
ng hindi nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na
14 araw?)
4. Have you traveled outside the Philippines in the last 14 days? (Ikaw ba ay nagbyahe
sa labas ng Pilipinas sa nakalipas na 14 na araw?)
5. Have you traveled outside the current city/municipality where you reside? (Ikaw ba
ay nagbyahe sa labas ng iyong lungsod/munisipyo?) If yes, specify which
city/municipality you went to (Sabihin kung saan) :
___________________________
I hereby certify that the information given is true, correct and complete. I understand that any falsified response may have
serious consequences. I understand that my personal information is protected by RA 10173 or the Data Privacy Act of 2012
and that this form will be destroyed after 20 days from the date of accomplishment, following the National Archives of the
Philippines protocol.
Signature (Lagda) :___________________________________________________

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