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  • Health Declaration Form English

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    DoyTan
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    This 3 sentence summary provides the key details from the Health Declaration Form: The form collects personal information such as name, age, occupation and travel history over the past 30 days from the individual filling it out. It asks if the person has experienced any symptoms like fever, cough or difficulty breathing recently or visited any hospitals, animal markets or slaughterhouses. By signing, the individual verifies the information is true and correct and allows the medical center to use it in accordance with local law.

    Original Description:

    Original Title

    HEALTH DECLARATION FORM ENGLISH

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    © © All Rights Reserved

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    This 3 sentence summary provides the key details from the Health Declaration Form: The form collects personal information such as name, age, occupation and travel history over the past 30 days from the individual filling it out. It asks if the person has experienced any symptoms like fever, cough or difficulty breathing recently or visited any hospitals, animal markets or slaughterhouses. By signing, the individual verifies the information is true and correct and allows the medical center to use it in accordance with local law.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    57 views1 page

    Health Declaration Form English

    Uploaded by

    DoyTan
    This 3 sentence summary provides the key details from the Health Declaration Form: The form collects personal information such as name, age, occupation and travel history over the past 30 days from the individual filling it out. It asks if the person has experienced any symptoms like fever, cough or difficulty breathing recently or visited any hospitals, animal markets or slaughterhouses. By signing, the individual verifies the information is true and correct and allows the medical center to use it in accordance with local law.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    Reason for Travel:

    ______ Work/Business
    HEALTH DECLARATION FORM ______ Vacation
    Instructions: Please accomplish this checklist ______ Home
    truthfully, for you and your family/community’s
    safety and protection. Thank you ______ Education

    Part 1: Others: ________________________________

    Name: Name and Address of Hotel stayed in:

    ________________________________________ _______________________________________

    Gender: ____M ____F _______________________________________

    Temp: _________________ In the past 30 days:

    Address: _________________________________ Did you visit any health worker, hospital, clinic?

    _________________________________________ _____ Yes (Specify) ________________________

    _________________________________________ _____ No

    Birthday: _________________________________ Did you visit any zoo, poultry farm, animal market,
    slaughter house?
    Age: __________
    _____ Yes (Specify) ________________________
    Mobile/Telephone Number: __________________
    _____ No
    Email Address: ____________________________
    Did you take any Fever Medications?
    Occupation:
    ________________________________________ _____ Yes (Specify) ________________________

    Part 2: _____ No

    Reason for Consultation/Admission: ____________ Did you take any Cough Medications?

    _________________________________________ _____ Yes (Specify) ________________________

    Foreign Countries or Places in the Philippines you _____ No


    have visited/worked in the past 30 days, specify Do you have any household members, close
    date of departure and arrival: friends, relatives you have met lately having fever,
    _________________________________________ cough, and/or any respiratory problems?

    _________________________________________ _____ Yes (Specify) ________________________

    _________________________________________ _____ No

    Have you been sick in the past 30 days? Do you have any relatives, friends, neighbors that
    you have met lately who arrived from any other
    _____Yes, (Describe Condition): country or city?
    _________________________________________ _____ Yes (Specify) ________________________
    ______No _____ No
    Did you have any of the following in the past 30
    days:
    The information I have provided herein is true and
    ____ Fever ____ Colds ____ Cough correct. I authorize EYV Medical Corporation to use
    this information in accordance with Philippine law. If
    ____ Sore Throat ____ Diarrhea
    caught providing wrong or dishonest information, I
    ____ Difficulty in Breathing ____ Body Weakness will be held accountable for my actions.

    Part 3 _______________________________________
    In the past 30 days did you travel by: Printed Name & Signature (Patient / Guardian)
    _____ Air (Specify) _________________________ Date: ________________________
    _____ Land (Specify) _______________________
    _____ Sea (Specify) ________________________

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