Health Declaration Form v2.0

DateApplied:

Last Name:

First Name:

Middle Name:

Gender: --Select-- Male Female

Age:

Contact Number:

Email Address:

Home Address:

Question 1 Foreign countries you have worked, visited, transited or traveled to for the past 30 days? Enter 'None' if not applicable. Please separate countries with a comma ( , )

Question 2 Cites of the Philippines you have worked, visited, lived or traveled to for the past 30 days? Enter 'None' if not applicable. Please separate countries with a comma ( , )

Question 3 Have you been sick in the pask 30 days? --Select-- No Yes

Question 4 Did you have any of the following in the last 30days fever, cold, cough, sure throat, loss of smelss or difuculty in breathing? --Select-- No Yes

Question 5 Did you visit any health worker, hospital, clinic or nursing home? --Select-- No Yes

Question 6 Where you confined in a hospital? --Select-- No Yes

Question 7 Do you have any household member/s, or close friend who meet a peron currently having fever, cough and or respiratory problems? --Select-- No Yes

Question 8 Did you take anti-fever medication during the last 4-6 hours? --Select-- No Yes

Question 9 Have you been in close contact with farm animals or expose to wild animals for the past 14 days? --Select-- No Yes