PHILIPPINE DENTAL ASSOCIATION INC.

AVALA'AVENUE corner KAMAGONG STREET, SAN ANTONIO VILLAGE TELEPHONE: (632) 890-4609
MAKATI CITY, METRO MANILA, PHILIPPINES 1203 (632) 897-8091
Website: \^/\^/\^/.Dda.Dh Email: Ddaofficel908@gmail.com FACSIMILE: (632) 899-6332

Philippine Dental Association Covid 19 Monitoring Form

This form is made exclusively for Dentist who have undergone a covid 19 test (Rapid Test or Swab Test) and was
confirmed positive to SARS-COV 2 virus. The data to be collected shall be used strictly to help monitor the number
of dentists afflicted and likewise help the association create policies and recommendations to the government in
the interest of public health.
We are hoping for your full cooperation to answer the questions as truthful and complete as you can. Rest assured
that we would treat the data with strict confidentiality.

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Bank Acct. Name (preferably dentist acct.) Name/Acct. No: 3¢
HMO: Expiration Date:
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B: Covid Tracing
Type of Test:
4' RT-PCRSwabTest RT-PCR Saliva Test
Date of Test: /-/?' £2J Name of Laboratory
History of Exposure: Dental clinic Hospital Household
patient as in-patient Husband/Wife
Assistant/Secretary as out-patient Children

Associate Dentist Household Help

Other Sources •,I N drlJ9_l'____PJ_I_
Blood Type BIood Pressure
Symptoms Experienced: Asymptomatic Mild Moderate Severe
Symptoms:
headache ±cough colds difficulty of breathing
/ fever/chill loss of smell / sorethroat nausea or vomiting
chestpain ' lossof appetite ifatigue high blood pressure
confusion / muscle pain diarrhea low blood pressure
Other symptoms:

C: Past Medical History

1. Have you or any members of your household travelled to any areaswith known cases ofcovID 19?
'MO
(state the exact location)
2. Any other member of your household whotested covID 19 positive?
3. Have you been tested covID 19 positive before?
4. Are you under medical treatment now? lfso, what is the condition being treated?
A/a
5. Have you ever been hospitalized? lfso, when and why?

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