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    Health Declaration Form: Symptoms

    Uploaded by

    Cyrell Castroverde Papauran
    1. This document is a health declaration form asking for personal information such as name, address, contact details, and recent travel history. 2. It asks if the individual has experienced common COVID-19 symptoms in the last 14 days or had contact with confirmed COVID-19 cases. 3. The individual certifies that their responses are true and acknowledges that failure to disclose or providing false information could have serious legal consequences.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Health Declaration Form: Symptoms

    Uploaded by

    Cyrell Castroverde Papauran
    195 views1 page
    1. This document is a health declaration form asking for personal information such as name, address, contact details, and recent travel history. 2. It asks if the individual has experienced common COVID-19 symptoms in the last 14 days or had contact with confirmed COVID-19 cases. 3. The individual certifies that their responses are true and acknowledges that failure to disclose or providing false information could have serious legal consequences.

    Original Description:

    Health Declaration form of learners

    Original Title

    Health-Declaration-Form

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    1. This document is a health declaration form asking for personal information such as name, address, contact details, and recent travel history. 2. It asks if the individual has experienced common COVID-19 symptoms in the last 14 days or had contact with confirmed COVID-19 cases. 3. The individual certifies that their responses are true and acknowledges that failure to disclose or providing false information could have serious legal consequences.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    195 views1 page

    Health Declaration Form: Symptoms

    Uploaded by

    Cyrell Castroverde Papauran
    1. This document is a health declaration form asking for personal information such as name, address, contact details, and recent travel history. 2. It asks if the individual has experienced common COVID-19 symptoms in the last 14 days or had contact with confirmed COVID-19 cases. 3. The individual certifies that their responses are true and acknowledges that failure to disclose or providing false information could have serious legal consequences.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Health Declaration Form

    Full Name (Buong Pangalan): Date (Petsa):


    Time (Oras):
    Complete Current Address (Kasalukuyang tirahan):

    Mobile/ Phone Number (Numero ng telepono):


    Email Address:

    Put a check mark on the appropriate column of your response. (Lagyan ng check sa angkop na sagot).
    Yes(Oo) No(Hindi) List of Symptoms (per DOH
    1. Are you a. Fever (Lagnat) DM 2020-0512)
    experiencing or did b. Cough and/ or Colds (Ubo at/o sipon) Symptoms
    you have any of the c. Body pains (Pananakit ng katawan)
    following in the last d. Sore throat (Pananakit o pamamaga ng  Fever
    14 days? (Ikaw ba lalamunan)
    ay may naranasan  Cough
    e. Fatigue/ Tiredness (Pagkapagod)
    o nakaranas ng f. Headache (Pananakit ng ulo)
     General Weakness
    mga simtomas sa  Fatigue
    g. Diarrhea (Pagatatae)
    loob ng 14 araw?)  Headache
    h. Loss of taste or smell (Nawalan ng panlasa o
    pang- amoy)  Myalgia
    i. Difficulty of breathing (Pagkahapo o hirap sa
     Sore throat
    paghinga)
    2. Have you had face-to-face contact with a probable or confirmed  Coryza
    COVID-19 case within 1 meter and for more than 15 minutes for the  Dyspnea
    past 14 days? (May nakasalamuha ka ba na maaaring o  Anorexia
    kumpirmadong pasyente na may COVID-19 mula sa isang metrong  Nausea
    distansya o mas malapit pa at tumagal ng mahigit 15 minuto sa
    nakalipas na 14 araw?  Vomiting
    3. Have you provided direct care for a patient with probable or  Diarrhea
    confirmed COVID-19 case without using proper “Personal Protective  Altered Mental
    Equipment (PPE)” for the past 14 days? (Nag-alaga ka ba ng Status
    maaaring o kumpirmadong pasyente na may COVID-19 na hindi
     Anosmia (Loss of
    nakasuot nf tamang PPE(Personal Protective Equipment) sa
    nakalipas na araw? smell)
    4. Have you traveled outside the Philippines in the last 14 days? (Ikaw  Aeusia (Loss of
    ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 araw?) taste)
    5. Have you traveled outside the current city or municipality where  Others _________
    you reside? (Ikaw ba ay nagbiyahe sa labas ng iyong lungsod/
    munisipyo?) If yes, specify which municipality/ city you went to
    (Sabihin kung saan) : I hereby certify that the information
    ___________________________________________________ given is true, correct and complete.
    Please check if you have any of the
    following at present or during
    I understand that failure to answer any question or any falsified response the past 14 days:
    may have serious consequences. I understand that my personal information ( ) fever >37.5 C ( ) loss of smell or taste
    is protected by RA 10173 or the Data Privacy Act of 2012 and that this form ( ) cough ( ) fatigue
    will be destroyed after 20 days from the date of accomplishment, following ( ) difficulty of breathing ( ) diarrhea
    the National Archives of the Philippines protocol. ( ) body weakness ( ) body aches
    ( ) sore throat ( ) cold/ runny nose
    ( ) headache ( ) nausea/ vomiting

    Signature (Lagda): _____________________

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