HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Full Name (Buong Pangalan) _______________________ Full Name (Buong Pangalan) _______________________
Date (Petsa) ________________ Date (Petsa) ________________
Time (Oras) ________________ Time (Oras) ________________
Complete Current Address (Kasalukuyang Tirahan) Complete Current Address (Kasalukuyang Tirahan)
______________________________________________ ______________________________________________
Mobile/ Tel. Number (Numero ng Telepono) ___________ Mobile/ Tel. Number (Numero ng Telepono) ___________

Put a check mark on the appropriate column of your response. Put a check mark on the appropriate column of your response.
(Lagyan ng tsek sa angkop na sagot) (Lagyan ng tsek sa angkop na sagot)
Yes No Yes No
1. Are you experiencing a. Fever (Lagnat) 1. Are you experiencing a. Fever (Lagnat)
or did you have any of b. Cough and/or Colds or did you have any of b. Cough and/or Colds
the following symptoms (Ubo at/o sipon) the following symptoms (Ubo at/o sipon)
in the last 14 days? c. Body pains in the last 14 days? c. Body pains
(Ikaw ba ay may (Pananakit ng (Ikaw ba ay may (Pananakit ng
katawan) katawan)
nararanasan o nararanasan o
d. Sore throat d. Sore throat
nakaranas ng mga (Pananakit o nakaranas ng mga (Pananakit o
sumusunod na sintomas pamamaga ng sumusunod na sintomas pamamaga ng
sa nakaraang 14 na lalamunan) sa nakaraang 14 na lalamunan)
araw?) e. Fatigue araw?) e. Fatigue
(Pagkapagod) (Pagkapagod)
f. Headache f. Headache
(Pananakit ng Ulo) (Pananakit ng Ulo)
g. Diarrhea (Pagtatae) g. Diarrhea (Pagtatae)
h. Loss of taste or h. Loss of taste or
smell (Nawalan ng smell (Nawalan ng
panlasa o pangamoy) panlasa o pangamoy)
i. Difficulty of breathing i. Difficulty of breathing
(Pagkahapo o hirap sa (Pagkahapo o hirap sa
paghinga) paghinga)
2. Have you had face-to-face contact with a probable 2. Have you had face-to-face contact with a probable
or confirmed COVID-19 case within 1 meter and for or confirmed COVID-19 case within 1 meter and for
more than 15 minutes for the past 14 days? (May more than 15 minutes for the past 14 days? (May
nakasalamuha ka ba na maaaring o kumpirmadong nakasalamuha ka ba na maaaring o kumpirmadong
pasyente na may COV/D-19 mu/a sa isang metrong pasyente na may COV/D-19 mu/a sa isang metrong
distansya or mas malapit pa at tumagal ng mahigit 15 distansya or mas malapit pa at tumagal ng mahigit 15
minuto sa nakalipas na 14 araw?) minuto sa nakalipas na 14 araw?)

3. Have you provided direct care for a patient with 3. Have you provided direct care for a patient with
probable or confirmed COVID-19 case without using probable or confirmed COVID-19 case without using
proper "Personal Protective Equipment (PPE)" for the proper "Personal Protective Equipment (PPE)" for the
past 14 days? (Naga/aga ka ba ng maaring o past 14 days? (Naga/aga ka ba ng maaring o
kumpirmadong pasyente na may COV/D-19 ng hindi kumpirmadong pasyente na may COV/D-19 ng hindi
nakasuot ng tamang PPE (Personal Protective nakasuot ng tamang PPE (Personal Protective
Equipment) sa nakalipas na 14 araw?) Equipment) sa nakalipas na 14 araw?)

4. Have you traveled outside the Philippines in the last 4. Have you traveled outside the Philippines in the last
14 days? (lkaw ba ay nagbiyahe sa labas ng Pilipinas 14 days? (lkaw ba ay nagbiyahe sa labas ng Pilipinas
sa nakalipas na 14 na araw?) sa nakalipas na 14 na araw?)

5. Have you traveled outside the current province 5. Have you traveled outside the current province
where you reside? (lkaw ba ay nagbiyahe sa labas ng where you reside? (lkaw ba ay nagbiyahe sa labas ng
iyong probinsya?) iyong probinsya?)
If yes, specify which province you went to If yes, specify which province you went to
(Sabihin kung saan): ______________ (Sabihin kung saan): ______________

I hereby certify that the information given is true, correct and complete. I I hereby certify that the information given is true, correct and complete. I
understand that failure to answer any question or any falsified response understand that failure to answer any question or any falsified response
may have serious consequences. I understand that my personal may have serious consequences. I understand that my personal
information is protected by RA 10173 or the Data Privacy Act of 2012 information is protected by RA 10173 or the Data Privacy Act of 2012
and that this form will be destroyed after 20 days from the date of and that this form will be destroyed after 20 days from the date of
accomplishment, following the National Archives of the Philippines accomplishment, following the National Archives of the Philippines
protocol. protocol.

Signature (Lagda) :_____________________ Signature (Lagda) :______________________