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Health Declaration Form

This health declaration form asks individuals for personal information and to answer questions about COVID-19 symptoms, travel history, contact with COVID-19 positive individuals, and whether they have been advised to self-quarantine. The form requires a signature to declare that all information provided is true and accurate.

Uploaded by

JANET ILLESES
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
9 views

Health Declaration Form

This health declaration form asks individuals for personal information and to answer questions about COVID-19 symptoms, travel history, contact with COVID-19 positive individuals, and whether they have been advised to self-quarantine. The form requires a signature to declare that all information provided is true and accurate.

Uploaded by

JANET ILLESES
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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HEALTH DECLARATION FORM

Please fill out this form accurately and truthfully. Your health and the health of others are
important to us.

Personal Information
Name: ___________________________
Date of Birth: ______________________
Address: _________________________
Contact Number: ___________________

Health Questions Have you traveled internationally or to any


area with high COVID-19 cases in the last
Have you experienced any of the following
14 days?
symptoms in the last 14 days? (Please
check all that apply) • Yes
• No
• Fever (temperature above 100.4°F /
• Not applicable
38°C)
• Cough Have you been advised to self-quarantine or
• Shortness of breath or difficulty isolate by a healthcare provider or public
breathing health official?
• Sore throat
• Yes
• Loss of taste or smell
• Fatigue • No
• Muscle or body aches • Not applicable
• Headache
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
Have you been in contact with someone
who has tested positive for COVID-19 in the
last 14 days?

• Yes
• No
• Not sure
Declaration
I hereby declare that the information provided above is true and accurate to the best of my
knowledge. I understand the importance of disclosing this information for the safety and well-
being of others.
Signature: ________________________
Date: ____________________________

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