HEALTH SURVEY QUESTIONNAIRE

Please take a moment to answer the following questions about your current Health Status. The information generated for this survey
are personal and your answer will be treated with utmost confidentiality. Rest assured the information shall be used to guide DENR
Management on how to best address alternative work arrangements pursuant to CSC MC 10 s. 2020.

NAME: ____________________________ POSITION: ESTERO RANGER CONTACT #: ______________________

________________
CITY: ________________________BARANGAY: ____________ ESTERO: ___________________________________
ADDRESS:___________________________________________________________ DATE: ____________________

1. On a scale of 1 to 10, with being the highest, how healthy do you consider yourself? ______
2. Do you have any of the following medical condition or illness:
________ High blood pressure
________ Diabetes
________ Heart-related diseases
________ Kidney-related diseases
________ Lung-related diseases
________ Cancer
________ Others (Please specify:_____________________________________________)

3. Are you seeing any specialist/doctor? (Y/N) (Please specify:________________________)

4. Are you having any of the following treatments?

________ Dialysis
________ Chemotherapy
________ Radiation
________ Physical/Occupational Therapy
________ Others ) (Please specify:_________________________________)

5. Are you taking maintenance medicines? (Y/N) _______

6. How many medications have been prescribed by your physician that you have taken for the last 24 hours? _________

7. For female employees. Are you pregnant? (Y/N) ________

If yes,
• When is the baby’s estimated due date? ____________________
• Does your doctor have any special concerns about this pregnancy? (Y/N) ____
8. Are you living with any of the following?
_____ Age 21 and below
_____
√ Age 60 and above
_____ Pregnant
_____ Family member with serious or life-threatening illness or with history (e.g Cancer Survivor)

9. Have you been in the hospital for the last 2 months? (Y/N) _________
• If admitted, why were you admitted? _____________________________________
• If not admitted, please state the purpose of your visit ________________________

I declare under oath that I have personally accomplished this Health Survey Questionnaire which is a true, correct to the
best of my knowledge.
___________________________________
Signature
Thank you for your cooperation.
 CONTACT PERSON IN-CASE OF EMERGENCY
Please indicate the Information of your contact person or the person whom you trusted the most. This may help us to notify someone
when in-case something might happen to you on the field.

1. Name of the Contact Person: __________________________________________________________________________

2. Address of the Contact Person: ________________________________________________________________________
3. Telephone or Mobile Number of the Contact Person: _______________________________________________________
4. Relationship to your Contact Person: (ex: Wife/Asawa, Chairperson, Sibling/Kapatid, & etc.) _______________________