COVID-19 PROFILING FORM

Last Name,First Name, Middle Name Suffix Sex Cellphone no.

Category 1. Health Workers

(Pls. check) 2. Senior Citizen
3. Indigent
4.Unified personnel
5. Essential Worker
6. Other
Category ID
PhilHealth ID
Address

Province/Municipality/City
Birthdate (mm/dd/yyy)
Civil Status
Employment Status 1. Government
(Pls. check) 2. Private
3. Self-employed
4. Others
Profession Teacher
Providing Direct COVID-19 Care YES NO
Name of Employer
Address of Employer

Contact number of employer

Pregnancy status (if female) YES NO
With Allergy? 1. Food Allergy 4. Mold Allergy
(if yes pls. check) 2.Insect Allergy 5. PetAllergy
3. Latex Allergy 6. Pollen Allergy
With Co-Comorbidity? YES NO
(if yes pls. check) 1. Hypertension 4. Diabetes Mellitus
2. Heart Disease 5.Bronchial Asthma
3. Kidney Disease
Immunodeficiency Status Cancer
Others
COVID 19 History YES/NO if yes(mm/yyyy)
Classification of COVID 19 1. Asymptomatic 4. Severe
(if yes pls. check) 2. Mild 5. Critical
3. Moderate
Willing to be vaccinated? YES NO

Notified by: Signature of Client

Name & Signature Name & Signature