HEALTH DECLARATION FORM
HEALTH DECLARATION FORM
NAME:____________________________________________________AGE:______
ADDRESS:_________________________________________________SEX:_______
___EMPLOYEE (Unit) ___________
CP/TEL. NO.:________________
___STUDENT (College) __________
___VISITOR
NAME:____________________________________________________AGE:______
ADDRESS:_________________________________________________SEX:_______
___EMPLOYEE (Unit) ___________
CP/TEL. NO.:________________
___STUDENT (College) __________
___VISITOR
PLEASE ANSWER THE QUESTIONS HONESTLY.
CHECK (/) YOUR ANSWER.
PLEASE ANSWER THE QUESTIONS HONESTLY.
CHECK (/) YOUR ANSWER.
Do you have any of these symptoms within the 14 days period?
SYMPTOMS
YES NO
SYMPTOMS
FEVER
DIARRHEA
COUGH
SORE THROAT
COLDS
NO SENSE OF SMELL
YES
NO
Do you have any of these symptoms within the 14 days period?
SYMPTOMS
YES NO
SYMPTOMS
FEVER
DIARRHEA
COUGH
SORE THROAT
COLDS
NO SENSE OF SMELL
DIFFICULTY OF BREATHING
MUSCLE & JOINT PAIN
YES
NO
YES
NO
DIFFICULTY OF BREATHING
MUSCLE & JOINT PAIN
OTHER INFORMATION:
OTHER INFORMATION:
YES
NO
HISTORY OF TRAVEL/VISIT FROM ANY PLACE OUTSIDE ILOCOS NORTE?
IF YES, WHERE?
WHEN?
VISITORS/RELATIVES THAT COME FROM OTHER PLACE?
IF YES, WHERE?
WHEN?
EXPOSURE TO ANYONE WITH SYMPTOMS OF FEVER, COUGH, COLDS
OR DIARRHEA IN YOUR HOME, WORK, SCHOOL, OR ANY GATHERINGS
(BITHDAY, WAKES, FIESTA, ETC.)?
TAKING CARE OF RELATIVE/PATIENT AT HOME WITH SYMPTOMS OF
FEVER, COUGH, COLDS OR DIARRHEA?
VISITED/MONITORED BY BARANGAY HEALTH WORKERS/OFFICIALS?
HISTORY OF TRAVEL/VISIT FROM ANY PLACE OUTSIDE ILOCOS NORTE?
IF YES, WHERE?
WHEN?
VISITORS/RELATIVES THAT COME FROM OTHER PLACE?
IF YES, WHERE?
WHEN?
EXPOSURE TO ANYONE WITH SYMPTOMS OF FEVER, COUGH, COLDS
OR DIARRHEA IN YOUR HOME, WORK, SCHOOL, OR ANY GATHERINGS
(BITHDAY, WAKES, FIESTA, ETC.)?
TAKING CARE OF RELATIVE/PATIENT AT HOME WITH SYMPTOMS OF
FEVER, COUGH, COLDS OR DIARRHEA?
VISITED/MONITORED BY BARANGAY HEALTH WORKERS/OFFICIALS?
DECLARATION:
DECLARATION:
I hereby certify that all information is true and complete. I do understand that
any false/wrong information can be used by the court against me under Article 161
of the Revised Penal Code of the Philippines, RA 11332 “Law on Reporting
Communicable Diseases”.
I hereby certify that all information is true and complete. I do understand that
any false/wrong information can be used by the court against me under Article 161
of the Revised Penal Code of the Philippines, RA 11332 “Law on Reporting
Communicable Diseases”.
__________________________
Signature
_____________
Date
__________________________
Signature
_____________
Date