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Health. Work. Life.
Daily Health Declaration (Visitor) Form
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.
1. Personal Information
2. Current Medical Conditions
3. Exposure History and Other Information
4. Symptoms
1. Personal Information
Visitor Type:
Others (Physician, Avega, Intellicare, Fullerton, etc..):
Worksite or Clinic Branch:
Last Name:
First Name:
Middle Name:
Gender:
Birthday:
Civil Status:
Email Address:
Mobile Number:
Valid ID:
(e.g SSS, Philhealth, Driver's License, Company ID, etc..).
Text
Barangay/Village/Subdivision:
Municipality/City:
Province:
Country:
Company:
Purpose of the Visit:
Note: Please tick (done) your answer/s.

2. Current Medical Conditions:

Pregnancy, Number of Weeks (Age of Gestation):
Others, please specify here:
Medications, if any (include dosage):
Note: Please choose (radio_button_checked) your answer/s.

3. Exposure History and Other Information
a. Did you travel in the last 14 days?

a.1. If yes, what type of travel?

a.2. If yes, where did you travel?
a.3. If yes, when did you travel (please indicate departure date and arrival date)?
b. Did you have close contact with a probable or confirmed COVID-19 case in the last 14 days (poorly ventilated indoor area, distance less than 1 meter, unprotected /no PPE, exposure greater than 15 minutes)?

b.1. If yes, when did you have contact with a probable or confirmed COVID-19 case in the last 14 days?
c. Were you advised to undergo any of the following in the last 14 days?

2.a. Reason for self isolation?
2.b. Date and duration of self isolation (number of days)
2.c. Were you monitored by the local health office or officer (Health Facility Administrative and maintenance staff, BHERT, City Health Office, physicians, nurse, etc.)?

3.a. Reason for home quarantine?
3.b. Date and duration of for home quarantine (number of days)
3.c. Were you monitored by the local health office or officer (Health Facility Administrative and maintenance staff, BHERT, City Health Office, physicians, nurse, etc.)?

4.a. Reason for hospitalization?
4.b. Duration of hospitalization (number of days)
4.c. Name of hospital
4.d. If hospitalized, please provide a copy of clinical abstract or discharge summary from the hospital where you were confined. [PDF, WORD, JPG, JPEG, PNG]
File
d. Were you tested for SARS-CoV-2 (COVID-19)?

e. What type of test was done?

1.a. What is the result of RT-PCR?

1.b. When was the RT-PCR test done?
2.a What is the result of Rapid Antigen Test?

2.b. When was the Rapid Antigen Test done?
3.a. What is the result of Rapid Antibody Test?

3.b. When was the Rapid Antibody Test done?
4.a If others, name of test?
4.b If others, test result?
e. Were there other tests done not mentioned above (e.g. Chest X-ray, CT Scan, MRI, Ultrasound or Other blood test)?

c.1. When were the other tests done?
e.2. Please specify the tests done.
f. Have you been vaccinated against COVID-19?

f.1. What is the name of the vaccine?
f.2. When was the first (1st) dose?
f.3. When will be/was the second (2nd) dose?
f.4. Vaccine Booster (Others)
f.5. Vaccine Booster When
4. Symptoms
Please tick (✓) if you are experiencing any of these symptoms in the last 14 days.