BCMDDC COVID-19 HEALTH CHECKLISTS BCMDDC CO

PERSONAL DATA
Name: Name:
(Last Name, First Name, Middle Name) (Last Name, First Name, Middle Na
Age: Sex: Civil Status: Nationality: Age:

Contact number: Contact number:

Present address: Present address:

TRAVEL HISTORY
Please list down the 2 most recent places you visited before arriving in Baybay City (within 30 days) Please list down the 2 most r
Name of Place Visited Travel Date Period Mode of Transportation Plate No./Voyage No. Name of Place Visited
1 1
2 2
MEDICAL HISTORY: MEDICAL HISTORY:

Are you experiencing/suffering from any of the following symptoms? (within 14 days) Are you experiencing/
FEVER ( ) YES ( )NO In the course of your travel, do you think you were FEVER
COUGH ( ) YES ( )NO exposed to the covid-19 virus? COUGH
SHORTNESS OF BREATH ( ) YES ( )NO SHORTNESS OF BREATH
DIARRHEA ( ) YES ( )NO ( ) YES ( )NO DIARRHEA

BCMDDC COVID-19 HEALTH CHECKLISTS BCMDDC CO

PERSONAL DATA
Name: Name:
(Last Name, First Name, Middle Name) (Last Name, First Name, Middle Na
Age: Sex: Civil Status: Nationality: Age:

Contact number: Contact number:

Present address: Present address:

TRAVEL HISTORY
Please list down the 2 most recent places you visited before arriving in Baybay City (within 30 days) Please list down the 2 most r
Name of Place Visited Travel Date Period Mode of Transportation Plate No./Voyage No. Name of Place Visited
1 1
2 2
MEDICAL HISTORY: MEDICAL HISTORY:

Are you experiencing/suffering from any of the following symptoms? (within 14 days) Are you experiencing/
FEVER ( ) YES ( )NO In the course of your travel, do you think you were FEVER
COUGH ( ) YES ( )NO exposed to the covid-19 virus? COUGH
SHORTNESS OF BREATH ( ) YES ( )NO SHORTNESS OF BREATH
DIARRHEA ( ) YES ( )NO ( ) YES ( )NO DIARRHEA
 BCMDDC COVID-19 HEALTH CHECKLISTS
PERSONAL DATA
Name:
(Last Name, First Name, Middle Name)
Sex: Civil Status: Nationality:

Contact number:

Present address:

TRAVEL HISTORY
Please list down the 2 most recent places you visited before arriving in Baybay City (within 30 days)
Travel Date Period Mode of Transportation Plate No./Voyage No.

MEDICAL HISTORY:

Are you experiencing/suffering from any of the following symptoms? (within 14 days)
( ) YES ( )NO In the course of your travel, do you think you were
( ) YES ( )NO exposed to the covid-19 virus?
( ) YES ( )NO
( ) YES ( )NO ( ) YES ( )NO

BCMDDC COVID-19 HEALTH CHECKLISTS

PERSONAL DATA
Name:
(Last Name, First Name, Middle Name)
Sex: Civil Status: Nationality:

Contact number:

Present address:

TRAVEL HISTORY
Please list down the 2 most recent places you visited before arriving in Baybay City (within 30 days)
Travel Date Period Mode of Transportation Plate No./Voyage No.

MEDICAL HISTORY:

Are you experiencing/suffering from any of the following symptoms? (within 14 days)
( ) YES ( )NO In the course of your travel, do you think you were
( ) YES ( )NO exposed to the covid-19 virus?
( ) YES ( )NO
( ) YES ( )NO ( ) YES ( )NO