Health Declaration Form

*Date
*Name First Name
Middle Name
Last Name
Contact Number
Address
Department to Visit

Are you experiencing any of the following symptom/s (Nakakaranas ka ba ng mga ganitong sintomas)?

Fever (Lagnat) (greater than or equal to 37.6°C)	YesNo	Cough (Ubo)	YesNo
Colds (Sipon)	YesNo	Muscle and body pains (Pananakit ng katawan)	YesNo
Sore Throat (Pananakit ng lalamunan)	YesNo	Shortness of breath (Kinakapos sa paghinga)	YesNo
Difficulty of breathing (Hirap sa paghinga)	YesNo	Diarrhea (Pagtatae)	YesNo
Decreased sense of smell (Problema sa pag-amoy)	YesNo	Decreased sense of taste (Problema sa panlasa)	YesNo

Have you worked together or stayed in the same closed environment of a confirmed COVID-19 case without wearing proper personal protective equipment (May nakasama ka ba o nakakatrabaho na kumpirmadong may sakit na dulot ng COVID-19 na walang suot na proteksyon)?
Yes
No

Have you had any close contact with anyone with fever, cough, colds, sorethroat, body pain, shortness of breath, or difficulty in breathing in the past 2 weeks (Mayroon ka bang nakasama na may lagnat, ubo, sipon, sakit ng lalamunan, sakit ng katawan o hirap sa paghinga)?
Yes
No

Are you recently diagnosed as a suspect/ probable/ confirmed case of COVID-19 (Nasuri ka ba kamakailan na mayroong sakit dulot ng COVID-19)? Yes
No

Have you traveled outside the Philippines in the last 14 days (Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw)? Yes
No

Have you traveled outside Metro Manila where there is an existing Enhanced Community Quarantine in the last 14 days (Ikaw ba ay nagbiyahe sa labas ng Metro Manila na may kasulukuyang ipinatutupad na ECQ sa nakalipas na 14 na araw)?
Yes
No

Do you live in an area where there is an existing ECQ (Ikaw ba ay nakatira sa isang lugar kung saan may kasulukuyang ipinatutupad na ECQ)? Yes
No

Jose R. Reyes Memorial Medical Center Health Declaration Form