Health Declaration Checklist
Important Reminder:
You must provide TRUTHFUL information about your health condition and possible exposure. Any falsification is PUNISHABLE with one to six months IMPRISONMENT and a 20,000 to 50,000 FINE (Republic ACT 11332). The information on this form is strictly confidential.
Please check if you have any of the following at present or during the past 14 days.
Please enumerate, if any, cities in the Philippines you have lived, worked, transited in the past 14 days:
Please enumerate, if any, foreign countries you have lived, worked, transited in the past 14 days:
Please check the appropriate:
In the last 14 days, have you been in close contact or exposed to any person suspected of Covid-19?
Were you confined in a hospital/health care facility during the past 14 days?
Have you been diagnosed to have pneumonia in the past 14 days?
Do you visit any health facility, hospital or clinic in the past 14 days?
Do you have any household member/s or close contacts who are currently having fever, cough, or any respiratory problems?
In the last 14 days, have you been in contact with a Covid-19 confirmed person?
If yes, when did this contact or person tested positive for RT-PCR?
Have you undergone any test for SARS-COV2 for the past 14 days?
If yes, what was the test type?
Where was the test done?
Date of release:
By signing, I hereby certify that the above statements are true and correct to the best of my knowledge.
Medicina de Pagsanjan
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