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  • Health Form

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    Linlen Viagedor
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    The document contains a health form asking individuals if they are experiencing any COVID-19 symptoms such as fever, cough, difficulty breathing, sore throat, diarrhea, fatigue, headache, loss of taste or smell, or body pains. It instructs them to check yes or no and sign and date the form, certifying that the information is true and understanding there may be consequences for falsified responses. The form is repeated with different temperatures listed.

    Original Description:

    health form

    Original Title

    HEALTH FORM

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    The document contains a health form asking individuals if they are experiencing any COVID-19 symptoms such as fever, cough, difficulty breathing, sore throat, diarrhea, fatigue, headache, loss of taste or smell, or body pains. It instructs them to check yes or no and sign and date the form, certifying that the information is true and understanding there may be consequences for falsified responses. The form is repeated with different temperatures listed.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    6 views1 page

    Health Form

    Uploaded by

    Linlen Viagedor
    The document contains a health form asking individuals if they are experiencing any COVID-19 symptoms such as fever, cough, difficulty breathing, sore throat, diarrhea, fatigue, headache, loss of taste or smell, or body pains. It instructs them to check yes or no and sign and date the form, certifying that the information is true and understanding there may be consequences for falsified responses. The form is repeated with different temperatures listed.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    °C °C

    HEALTH FORM HEALTH FORM


    Are you experiencing any symptoms related to COVID_19 such as: Are you experiencing any symptoms related to COVID_19 such as:

    ____a. Fever ____f. Fatigue/Tiredness ____a. Fever ____f. Fatigue/Tiredness


    ____b. Cough and colds ____g. Headache ____b. Cough and colds ____g. Headache
    ____c. Difficulty of breathing ____h. Loss of taste or smell ____c. Difficulty of breathing ____h. Loss of taste or smell
    ____d. Sore throat ____i. Body pains ____d. Sore throat ____i. Body pains
    ____e. Diarrhea ____e. Diarrhea
    ________________Put a check mark (/)______________________ ________________Put a check mark (/)______________________

    ____YES ______NO ____YES ______NO


    I hereby certify that the information given is true, correct and complete. I hereby certify that the information given is true, correct and complete.
    I understand that any falsified response may have serious I understand that any falsified response may have serious
    consequences. consequences.

    ________________________________ ______________ ________________________________ ______________


    Name and Signature Date Name and Signature Date

    °C °C
    HEALTH FORM HEALTH FORM
    Are you experiencing any symptoms related to COVID_19 such as: Are you experiencing any symptoms related to COVID_19 such as:

    ____a. Fever ____f. Fatigue/Tiredness ____a. Fever ____f. Fatigue/Tiredness


    ____b. Cough and colds ____g. Headache ____b. Cough and colds ____g. Headache
    ____c. Difficulty of breathing ____h. Loss of taste or smell ____c. Difficulty of breathing ____h. Loss of taste or smell
    ____d. Sore throat ____i. Body pains ____d. Sore throat ____i. Body pains
    ____e. Diarrhea ____e. Diarrhea
    ________________Put a check mark (/)______________________ ________________Put a check mark (/)______________________

    ____YES ______NO ____YES ______NO


    I hereby certify that the information given is true, correct and complete. I hereby certify that the information given is true, correct and complete.
    I understand that any falsified response may have serious I understand that any falsified response may have serious
    consequences. consequences.

    ________________________________ ______________ ________________________________ ______________


    Name and Signature Date Name and Signature Date

    HEALTH FORM °C HEALTH FORM °C

    Are you experiencing any symptoms related to COVID_19 such as: Are you experiencing any symptoms related to COVID_19 such as:

    ____a. Fever ____f. Fatigue/Tiredness ____a. Fever ____f. Fatigue/Tiredness


    ____b. Cough and colds ____g. Headache ____b. Cough and colds ____g. Headache
    ____c. Difficulty of breathing ____h. Loss of taste or smell ____c. Difficulty of breathing ____h. Loss of taste or smell
    ____d. Sore throat ____i. Body pains ____d. Sore throat ____i. Body pains
    ____e. Diarrhea ____e. Diarrhea
    ________________Put a check mark (/)______________________ ________________Put a check mark (/)______________________

    ____YES ______NO ____YES ______NO


    I hereby certify that the information given is true, correct and complete. I hereby certify that the information given is true, correct and complete.
    I understand that any falsified response may have serious I understand that any falsified response may have serious
    consequences. consequences.

    ________________________________ ______________ ________________________________ ______________


    Name and Signature Date Name and Signature Date

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