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Covid-19 Health Declaration
How are you feeling today?
First Name
Last Name
Email
Body Temperature
Age | Sex
Nationality
Date of Birth
Mobile / Telephone No.
Have you traveled withn or outside the Phlipines for the last 14 days? If yes, kindly indicate below:
Yes
No
Others
Add answer here
Do you have any of these symptoms, r have you ha any of thesee symptoms in the last 14 days? (Please check all that apply.)
Fever
Sore Throat
Cough
Severe Diarrhea
Body Weakness
Headache
Difficulty in breathing
N/A
Other:
Add answer here
Did you visit any healh clinic, hospital or nursing home in the past 14 days? If yes, kindly indicate specific establishment
Yes
No
Others
Add answer here
Have you been in contact with a suspeted or confirmed COVID-19 patient for thepast 14 days?
Yes
No
Do you have any family/household members or close friends who have met a person currently having flu-like symptoms (e.g feer, cough colds) or respiratory problems?
Yes
No
Have you undertaken any COVID Test? If yes, kindly provide the following information
Yes
No
Others
Thanks for submitting!
Submit
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