COVID-19 PERSONAL DISCLOSURE & TRIAGE TOOL

APPOINTMENT CONFIRMATION FORM

ALL SHOULD WEAR PROPER MASKS
NAME DATE/TIME:
Ma. Emilia Bulaong 06/23/20
Cardinal
Family Name Given Name Middle Name TEMPERATURE:
Age 69 Sex Female Birthday March 26, 1951 Contact No. 09175364542
Address 114 Sto. Cristo, Malolos City, Bulacan Email: emilycardinal0@gmail.com
Attending Physician Dr. Jericho Luna Appointment Date/Time: 6-24-2020/ 10am-12nn

PART I. SYMPTOMS (Mga Tanong ukol sa mga simtomas ng Covid)

(Do you have any of the following symptoms? If yes, when did it start?) Mayroon ba kayong nararamdaman na
mga ganitong simtomas? Kung OO, kalian?)

SYMPTOMS YES WHEN NO SYMPTOMS YES WHEN NO

Cough ubo Loss of Appetite kawalan ng gana

x x
Colds sipon Nausea &/or Vomiting pagsusuka
x x
Fever lagnat Body Weakness/ Muscle Pain
x panghihina ng katawan o pananakit x
Difficulty of Breathing ng kalamnam
hirap sa paghinga x Chills giniginaw na pakiramdam
Sore Throat masakit na
x x
lalamunan
Headache sakit ng ulo Eye Discharge/ Pink or Red Eyes
x pamumula ng mata
x
Diarrhea pagtatae x Skin Rash rashes
Bleeding pagdudugo sa
x
kahit na anong parte ng x Decreased sense of smell &/or taste
kawalan ng pangamoy o panlasa
x
katawan

PART II. EXPOSURE HISTORY (Mga tanong ukol sa pagkakataong nalantad sa Covid)
YES NO DETAILS
Have you been quarantined in the past 4 weeks? Date Petsa:
Kayo po ba ay na-quarantine nitong huling apat x
na linggo?
Have you or any of your close contacts or Result Resulta:
household members been tested for COVD-19? x Date of Testing Petsa ng testing:
Na testing na po ba kayo o mga kasamahan sa
bahay para sa covid?
Were you exposed to a suspect/probably/ Date of Exposure Petsa ng exposure:
confirmed case of COVID-19 during the past 14
days? Nitong huling labing-apat na araw kayo po x
ba ay na-expose sa taong nagka Covid o
posibleng nagka-Covid?
Did you have a Chest x-ray for the past 6 Result Resulta:
months? Nakapag pa X-ray na po ba kayo nung x
huling 6 na buwan?

PART III. TRAVEL HISTORY (Mga tanong ukol sa pagkakataong makapagbiyahe)

YES NO DETAILS
Have you been to other places (hospital/ lying-in/ Where Saan:
health center) before coming here? Reason of Transfer Dahilan inilipat:
Nanggaling ba po kayo sa ibang mga ospital o x
health center maliban sa CMC?
Have you or any member of your household Country Bansa:
travelled out of the country in the past 14 days? x Date of travel Petsa nasa abroad: From
Kayo po ba o mga kasama sa bahay ay to
nangibang-bansa nitong nakalipas na labing-apat
na araw?
Have you or any member of your household or
close contacts travelled to OR reside in an area
where there is a reported case of cluster of
COVID-19 (+) patients during the past 14 days?
x
Nitong huling labing-apat na araw, nanirahan o
nanatili po ba kayo o mga kasamahan nyo sa
bahay sa isang lugar na madaming kaso ng
Covid?
Page 1 of 2 Ref. Code: CMC-DMO M05-FM042
**See at the back Rev. 2, Effective Date: Jun 01, 2020
PART IV. MEDICATIONS: Please enumerate current medications you are taking.
Ano pong mga gamot ang iniinom ninyo sa ngayon, kung mayroon man?

Anti-HPN, anti-diabetic
In accordance with RA 11332 Mandatory Reporting of Notifiable Disease and Health Events of Public Health
Concern Act. It is required of the patient to provide truthful information about one’s health condition and possible
exposure. Violation of this act shall be PENALIZED with a fine of not less than Php 20,000.00 but not more than
Php 50,000.00 or imprisonment of not less than one (1) month but not more than six (6) months, or both such
fine and imprisonment at the discretion of the proper court.

I/We certify that the above declaration is TRUE and CORRECT. We understand that any dishonest answer
(s) may have serious public health implications and may be subjected to penalties.

Ma. Emilia B. Cardinal / 06-23-2020 Antonette Estrella / Niece

Printed Name and Signature/ Date & Time COMPANION’s Printed Name and Signature and Relationship

PART V. REMINDERS FOR THE TRIAGE NURSE/OFFICER/MSAA (Paalala sa mga Triage Nurse at mga
Medical Staff Assistant)

1. FOR PATIENTS UNDERGOING DIAGNOSTICS, COLLECT AT THE EXIT AND SUBMIT TO ICC AT END OF
SHIFT. (Para sa mga pasyente na sasailalim ng mga Diagnostics, ito ay dapat iwan sa paglabas at ibigay sa
ICC)
2. ALWAYS COLLECT AND SUBMIT TO ICC AT END OF SHIFT. (Lagi itong kunin mula sa nag-fillup at ibigay
sa ICC pagkatapos ng shift)
If there is a YES response to the questions, ENTRY IS NOT ALLOWED and IF
Kapag mayroong OO sa mga sagot, huwag munang papasukin at gawin ang sumusunod:

1. Patient- inform attending physician and wait for his/her disposition.

Pasyente- isangguni sa kanyang duktor

2. Doctor- refer to ICC for clearance

Duktor- isangguni sa ICC para sa clearance

3. CMC Employee/Healthcare Worker- inform Nursing Supervisor then ICC

Empleyado/Healthcare worker ng CMC- isangguni sa Nursing Supervisor at ICC

This is to certify that the patient was screened by: ___________________________ Date: __________________
(Attending Triage Officer)
--------------------------------------------------------------------------------------------------------------------------------------------
PROOF OF SCREENING / ROUTING SLIP

NAME DATE/TIME:

Family Name Given Name Middle Name Temperature:

Age Sex Birthday Contact No.
Attending Physician Appointment Date/Time:

ONLY FOR PATIENTS UNDERGOING DIAGNOSTIC EXAMINATIONS

(Para lang sa mga pasyenteng magpapa-laboratory o xray)
PURPOSE OF VISIT DONE
(Signature over printed name with date and time)
Dahilan ng pagpunta sa CMC
 Laboratory
Type of Test
Blood Donation
Chronic Disease monitoring:
 Cleared by Hotline
 With electronic request from Attending Physician
 Chemotherapy  Scheduled Time:
 Hemodialysis  Scheduled Time:
 Radiology
 Type of procedure:
 With request from Attending Physician
 Others, pls specify

Page 2 of 2 Ref. Code: CMC-DMO M05-FM042

Rev. 2, Effective Date: Jun 01, 2020