Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV - CALABARZON
Gov. Felicisimo T. San Luis Integrated SHS
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV - CALABARZON
Gov. Felicisimo T. San Luis Integrated SHS
HEALTH DECLARATION SURVEY FORM
Name: __________________________________Date:________________
Age: ________________Sex: _______________ Time:________________
Address: _____________________________________________________
Contact #: ____________________________________________________
Office to Visit: ___________________________ Temperature: _______
1. In the last 14 days up to present, have you experienced these
symptoms?
Sore throat
YES
NO
Cough
YES
NO
Colds
YES
NO
Body pain
YES
NO
Headache
YES
NO
Fever
YES
NO
Difficulty of breathing
YES
NO
2. If your answer is “YES” to any symptoms listed above, have
you had exposure 2 days before or within 14 days from the
onset of these symptoms to a confirmed or probable case?
Face-to-face contact with a
YES
NO
confirmed COVID 19 case within 1
meter and for more than 15 minutes
Direct physical contact with a
YES
NO
confirmed COVID 19 case
Direct care for a patient with a
YES
NO
probable/ confirmed COVID 19 case
with or without using proper
personal protective equipment (PPE)
3. In the last 14 days, have you travelled in another province,
city or country?
YES
NO If yes, specify the place: _______________
I hereby certify that the above information is true & correct.
HEALTH DECLARATION SURVEY FORM
Name: __________________________________Date:________________
Age: ________________Sex: _______________ Time:________________
Address: _____________________________________________________
Contact #: ____________________________________________________
Office to Visit: ___________________________ Temperature: _______
1. In the last 14 days up to present, have you experienced these
symptoms?
Sore throat
YES
NO
Cough
YES
NO
Colds
YES
NO
Body pain
YES
NO
Headache
YES
NO
Fever
YES
NO
Difficulty of breathing
YES
NO
2. If your answer is “YES” to any symptoms listed above, have
you had exposure 2 days before or within 14 days from the
onset of these symptoms to a confirmed or probable case?
Face-to-face contact with a
YES
NO
confirmed COVID 19 case within 1
meter and for more than 15 minutes
Direct physical contact with a
YES
NO
confirmed COVID 19 case
Direct care for a patient with a
YES
NO
probable/ confirmed COVID 19 case
with or without using proper
personal protective equipment (PPE)
3. In the last 14 days, have you travelled in another province,
city or country?
YES
NO If yes, specify the place: _______________
I hereby certify that the above information is true & correct.
______________________________
Signature
______________________________
Signature
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV - CALABARZON
Gov. Felicisimo T. San Luis Integrated SHS
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV - CALABARZON
Gov. Felicisimo T. San Luis Integrated SHS
HEALTH DECLARATION SURVEY FORM
Name: __________________________________Date:________________
Age: ________________Sex: _______________ Time:________________
Address: _____________________________________________________
Contact #: ____________________________________________________
Office to Visit: ___________________________ Temperature: _______
1. In the last 14 days up to present, have you experienced these
symptoms?
Sore throat
YES
NO
Cough
YES
NO
Colds
YES
NO
Body pain
YES
NO
Headache
YES
NO
Fever
YES
NO
Difficulty of breathing
YES
NO
2. If your answer is “YES” to any symptoms listed above, have
you had exposure 2 days before or within 14 days from the
onset of these symptoms to a confirmed or probable case?
Face-to-face contact with a
YES
NO
confirmed COVID 19 case within 1
meter and for more than 15 minutes
Direct physical contact with a
YES
NO
confirmed COVID 19 case
Direct care for a patient with a
YES
NO
probable/ confirmed COVID 19 case
with or without using proper
personal protective equipment (PPE)
3. In the last 14 days, have you travelled in another province,
city or country?
YES
NO If yes, specify the place: _______________
I hereby certify that the above information is true & correct.
HEALTH DECLARATION SURVEY FORM
Name: __________________________________Date:________________
Age: ________________Sex: _______________ Time:________________
Address: _____________________________________________________
Contact #: ____________________________________________________
Office to Visit: ___________________________ Temperature: _______
1. In the last 14 days up to present, have you experienced these
symptoms?
Sore throat
YES
NO
Cough
YES
NO
Colds
YES
NO
Body pain
YES
NO
Headache
YES
NO
Fever
YES
NO
Difficulty of breathing
YES
NO
2. If your answer is “YES” to any symptoms listed above, have
you had exposure 2 days before or within 14 days from the
onset of these symptoms to a confirmed or probable case?
Face-to-face contact with a
YES
NO
confirmed COVID 19 case within 1
meter and for more than 15 minutes
Direct physical contact with a
YES
NO
confirmed COVID 19 case
Direct care for a patient with a
YES
NO
probable/ confirmed COVID 19 case
with or without using proper
personal protective equipment (PPE)
3. In the last 14 days, have you travelled in another province,
city or country?
YES
NO If yes, specify the place: _______________
I hereby certify that the above information is true & correct.
______________________________
Signature
______________________________
Signature