NAME OF EMPLOYEE:

PHILHEALTH ID NUMBER
LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
CONTACT NO.
ADDRESS: STREET
-REGION
-PROVINCE
-MUNICIPALITY
-BARANGAY
SEX
BIRTHDATE
CIVIL STATUS
EMPLOYMENT STATUS
DIRECTLY IN INTERACTION WITH COVID PATIENT
PROFESSION
PREGNANCY STATUS
DRUG ALLERGY?
FOOD ALLERGY?
INSECT ALLERGY?
LATEX ALLERGY?
MOLD ALLERGY?
PET ALLERGY?
POLLEN ALLERGY?
WITH CO-MORBIDITY?
-HYPERTENSION
-HEART DISEASE
-KIDNEY DISEASE
-DIABETES MELLITUS
-BRONCHIAL ASTHMA
-IMMUNODEFICIENCY STATUS
-CANCER
-OTHERS
DIAGNOSED WITH COVID 19?
DATE OF FIRST POSITIVE RESULTS/DATE OF COLLECTION
CLASSIFICATION OF COVID 19
PROVIDED ELECTRONIC CONSENT? (IF YES, FF AND FORM)