Jose R. Reyes Memorial Medical Center Health Declaration Form
*Date
*Name
First Name
Middle Name
Last Name
Contact Number
Address
Department to Visit
ACCOUNTING
ADMITTING
ANESTHESIOLOGY
BAC-SEC
BEHAVIORAL MEDICINE
BILLING
BUDGET
CAO
CCU
CMPS
COLLECTING
CT AND MRI
CVU
DENTAL
DERMATOLOGY
DIALYSIS UNIT
DIRECTOR'S OFFICE
DISBURSING
DOH-BOTIKA
EMERGENCY SERVICE COMPLEX
ENGINEERING AND FACILITIES
ENT
FAMILY MEDICINE
FMO
GAD
GERIA
GGHS
HEMS
HIMD-MRS
HOUSEKEEPING
HRMDD
IHOMU
INSPECTION AND ACCEPTANCE UNIT
INTERNAL MEDICINE
INTERNAL MEDICINE (MEDICAL ONCOLOGY)
INTERNAL MEDICINE-DIALYSIS
LABORATORY
LEGAL UNIT
LINEN
MAIN OR
MEDI
MEDICAL TRAINING OFFICE
MMD
NDMD
NETRU
NEUROLOGY
NUCLEAR MEDICINE
NURSING OFFICE
OB-GYNECOLOGY
ONCOLOGY (SURGICAL)
OPD
OPHTHALMOLOGY
ORTHOPAEDICS
PATHOLOGY
PCU
PEDIATRICS
PHARMACY
PHARMACY (WELFARE)
PHIC AND CLAIMS DEPT
PHILHEALTH
PMD
PSYCHIATRY
PUBLIC HEALTH UNIT
PULMONARY UNIT
QMU
RADIOLOGY
RADIOLOGY - RECORDS
RADIOTHERAPY
REHAB. MEDICINE
SECURITY OFFICE
SOCIAL WORK
STATISTICS
SURGERY
SURGERY (NEURO)
TELEPHONE OPERATOR
UROLOGY
OTHERS
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)
Yes
No
Cough (Ubo)
Yes
No
Colds (Sipon)
Yes
No
Muscle and body pains (Pananakit ng katawan)
Yes
No
Sore Throat (Pananakit ng lalamunan)
Yes
No
Shortness of breath (Kinakapos sa paghinga)
Yes
No
Difficulty of breathing (Hirap sa paghinga)
Yes
No
Diarrhea (Pagtatae)
Yes
No
Decreased sense of smell (Problema sa pag-amoy)
Yes
No
Decreased sense of taste (Problema sa panlasa)
Yes
No
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