Health. Work. Life.
Daily Health Checklist
NOTE:
  1. YOUR MEDICAL HISTORY IS IMPORTANT TO US
    Intentional concealment of relevant information or refusal to cooperate by persons affected by a health event or public concern is a crime under the REPUBLIC ACT NO. 11332
  2. Please check your information before proceeding to the next page.
  3. Fields with asterisk (*) are mandatory.
Personal Information
Medical History
Symptoms
Exposure History
Basic Information
Employee ID or Valid ID Number:
Enter your Employee ID or Valid ID Number to search your record (if existing) and click corresponding result/name. And below fields will be filled up respectively.
Enter your Employee ID or ID Number to search your record (if existing) and click corresponding result/name. And below fields will be filled up respectively.
Full Name:
Company:
Work Site or Clinic Branch:
Department:
Email Address:
Medical Conditions
Note: Please check/tick appropriate choice.

Current Medical Conditions:

Medications, if any (include dosage):
Symptoms
Note: Please check/tick appropriate choice.

1. Do you have any of these symptoms in the past 14 days?

Exposure Histroy
Note: Please check/tick appropriate choice.

a). Did you travel to an area with local transmission of COVID-19?

a.1). If yes, when did you travel in an area with local transmission of COVID-19?
a.2). If yes, where did you travel in an area with local transmission of COVID-19?
b). Did you recently travel outside the country within the last 14 days?

b.1). If yes, when was your last travel outside the country?
c). Did you have close contact with confirmed COVID-19 case?

c.1). If yes, when did you have contact with a confirmed COVID-19 case?