Health Condition Form

Employee’s Name: _______________________ Date Accomplished: _________________

(Company) : ____________________________

To prevent the spread of COVID-19 and reduce the potential risk to our workforce, we are
conducting a simple screening questionnaire. Your participation is important to help us take
precautionary measures to protect you and everyone in the Company. Please fill appropriately.
Thank you for your time.

1. Where did you stay during the Enhanced Community Quarantine?

 Own Home
 Boarding House
 Others (please specify) ___________

2. What activities did you do during the Enhanced Community Quarantine?

a. _________________________________
b. _________________________________
c. _________________________________
d. _________________________________
e. _________________________________
3. How many are you in the household where you stayed during the Enhanced Community
Quarantine?
 1 - 5 household members
 6 - 10 household members
 10 - 15 household members
4. Is there a family member of your household or immediate family who is a medical
health worker?
 Yes Relationship ______________
 No
5. Is there a household member or immediate family member who has travelled to or
from other municipalities in the last three (3) weeks?
 Yes Relationship ______________
From which Municipality: ________________
 No
6. What are the places that you often visited during the Enhanced Community Quarantine?
 Mall Supermarket
 Public Market
 Office
 Others __________________
7. Have you had recent personal contact with anyone who has been classified with COVID
Suspect Case, COVID Probable Case?
 Yes Relationship ______________
 No
8. Please check any of the following signs and symptoms you have at present during the
last three (3) weeks:
 Fever _________ C
 Headache
 Severe Cough
 Difficulty of Breathing
  Colds
 Difficulty in urination
 Convulsion
 Others (Please specify) ___________________
9. Are there any medical conditions that you are feeling right now not included in the list
above?
 YES (please specify)
 NO
10. Are you staying alone in your house? (Yes/No) _______. If No, please check the
following areas and supplies in your house that are being shared:
 Kitchen
 Utensils
 Bathroom
 Toiletries
11. Did you seek any medical attention for the past year (2019) to present.
 YES (Please specify Medical Condition:______________________; Date of
Occurrence: ___________________; Date of Treatment:___________________)
 NO
12. If your answer is YES on Question #11, are you currently undertaking medical
treatment/s and maintenance medicine/s
 YES (Please specify) ______________________________
 NO
13. What is the mode of transportation you are using to go to work?
 Public Transportation. (Please specify)_______________________
 Private Transportation
 Others (Please specify) _________________________
14. How much time does it take you to reach the site of your work assignment?
 0-15 minutes
 15-30 minutes
 30 mins – 1 hour
 1 hour – 2 hours
 Others: _______________

I hereby certify that I have, to the best of my knowledge, answered truthfully the above
questions and understand that this information is important for the safety and health of
all employees.

_______________________________________
EMPLOYEE’S SIGNATURE OVER PRINTED NAME