Republic of the Philippines

DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
INFANTA INTEGRATED SCHOOL

HEALTH ASSESSMENT FORM

Date:______________ Time: ___________

PERSONAL INFORMATION:

Name: ____________________________________ Body Temperature: _______

Age: _________________ Sex: ____________

CONTACT DETAILS:

PHONE NUMBER: __________________________________

Address: __________________________________________

TRANSPORTATION:
Public: ____________ Private Commuter: __________

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
INFANTA INTEGRATED SCHOOL

HEALTH ASSESSMENT FORM

Date:______________ Time: ___________

PERSONAL INFORMATION:

Name: ____________________________________ Body Temperature: _______

Age: _________________ Sex: ____________

CONTACT DETAILS:

PHONE NUMBER: __________________________________

Address: __________________________________________

TRANSPORTATION:
Public: ____________ Private Commuter: __________
QUARANTINE RECORD:

Have you ever been sick of Medical History

any of the following in the Remarks (Consulted/Medication Taken, etc.)
YES NO
last 14 days
(Signs & Symptoms)
A. Fever
B. Cough
C. Sore Throat
D. Difficulty of Breathing
E. Others

TRAVEL HISTORY: (for the past 14 days)

Date: _________________ Place: _______________________________

I hereby certify that the above mentioned data are true and correct.

_____________________________
NAME AND SIGNATURE

QUARANTINE RECORD:

Have you ever been sick of Medical History

any of the following in the Remarks (Consulted/Medication Taken, etc.)
YES NO
last 14 days
(Signs & Symptoms)
A. Fever
B. Cough
C. Sore Throat
D. Difficulty of Breathing
E. Others

TRAVEL HISTORY: (for the past 14 days)

Date: _________________ Place: _______________________________

I hereby certify that the above mentioned data are true and correct.

_____________________________
NAME AND SIGNATURE