HEALTH DECLARATION FORM
NAME :
________Martinez_____________Richard Paul________________R.__________________________
Last
First
M.I.
HOME ADDRESS: #17 Avelino Street. Unit 302, Andres Bonifacio Barangay, Baguio City
AGE: 45 | GENDER: Male |CONTACT No. +639179906240
POINT OF ORIGIN:
(PINANGGALINGANG LUGAR)
Baguio City
PLACE OF DESTINATION IN BAGUIO CITY:
(LUIGAR NA PUPUNTAHAN / TUTULUYAN SA BAGUIO)
Baguio City
TRAVEL HISTORY
A. Have you been or have visited any of the following places in the last 14 days?
- MANILA
- NCR (National Capital Region)
- PANGASINAN
- LA UNION
- AREAS ON LOCKDOWN DUE TO COVID—19 POSITIVE CASES
B. Have you been or visted other regions /provinces or cities in the
last 14 days
YES ( )
NO (√)
YES ( )
NO (√)
YES ( )
NO (√)
YES ( )
NO (√)
YES ( )
NO (√)
YES ( )
NO (√)
Specify Where:
___________________________
YES ( )
C. Have you worked, visited, transited, or traveled in a foreign
country in the last 14 days?
NO (√)
Specify Where:
___________________________
CONTACT HISTORY
Have you ever lived with, cared for, or had direct contact with a
suspect (PUI) or confirmed case of COVID 19?
YES ( )
NO ( )
MEDICAL HISTORY
Have you been sick or experienced any of the following in the last 14 days?
(Nagkasakit ka ba sa mga sumusunod sa nakaraang 14 na araw?)
SICKNESS (KARAMDAMAN)
- FEVER (LAGNAT)
- COUGH (UBO)
- COLDS (SIPON)
- SORE THROAT (PANANAKIT NG LALAMUNAN)
- DIFFICULTY IN BREATHING (HIRAP SA PAGHINGA)
- DIARRHEA (MADALAS NA PAGDUMI)
YES ( )
NO (√)
YES ( )
NO (√)
YES ( )
NO (√)
YES ( )
NO (√)
YES ( )
NO (√)
YES ( )
NO (√)
OTHERS : ______________________________________________________________________________
DECLARATION: I hereby certify that the above information is true and complete. I understand that my failure to answer, or
any false or misleading information given by me may be used as a ground for the filing of cases against me under Articles 171
and 172 of the Revised Penal Code of the Philippines, or Republic Act No. 11332, otherwise known as the “Law on Reporting of
(Ako ay nagpapatunay na ang mga impormasyon na aking binigay ay totoo at
kumpleto. Naiintindihan ko na kung anumang maling impormasyon ay maaaring maging dahilan
para sa paghain ng kasong kriminal laban sa akin sa ilalim ng Article 171 at 172 ng Revised Penal
Code o sa ilalim ng Republic Act No. 11332).
Communicable Disease”.
______________10 August 2020____________
________Richard Paul R. Martinez_____ SIGNATURE OVER NAME
(PANGALANG AT PIRMA)
DATE (PETSA)
*As a precautionary measure by the City of Baguio against the transmission of COVID-19, pursuant to Proclamation No. 922, dated 8
March 2020, and the Section 16 of the Local Government Code