Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

Region III Region III
Schools Division of Bulacan Schools Division of Bulacan
District of Pandi North District of Pandi North
SAN ANTONIO ABAD ELEMENTARY SCHOOL SAN ANTONIO ABAD ELEMENTARY SCHOOL

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

DATE: _________________________ TIME IN: _______________ DATE: _________________________ TIME IN: _______________
NAME: __________________________________________________ NAME: __________________________________________________
BODY TEMPERATURE: _________________________________ BODY TEMPERATURE: _________________________________

Have you experience any of the following symptoms in the past 14 days? Have you experience any of the following symptoms in the past 14 days?
YES NO YES NO
Fever Fever
Dry cough Dry cough
Body Weakness Body Weakness
Headache Headache
LBM LBM
Runny nose Runny nose
Tiredness Tiredness
Sore throat Sore throat
Shortness of Breathness Shortness of Breathness
Loss of taste/smell Loss of taste/smell

Have you been in contact with any Covid-19 confirmed positive patients Have you been in contact with any Covid-19 confirmed positive patients
patients for the past 14 days? patients for the past 14 days?

YES NO YES NO