HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Date: _____________ Time: ____________ Date: _____________ Time: ____________

Personal Information: Personal Information:
Name: ______________________________ Name: ______________________________
Age: _______ Sex: __________ Age: _______ Sex: __________
Address: Address:
__________________________________ __________________________________
Contact# ____________________________ Contact# ____________________________

Current Health Condition: Current Health Condition:

Fever [ ] Yes [ ] No - temp. ___ºc Fever [ ] Yes [ ] No - temp. ___ºc
Cough [ ] Yes [ ] No Cough [ ] Yes [ ] No
Colds [ ] Yes [ ] No Colds [ ] Yes [ ] No
Sore Throat [ ] Yes [ ] No Sore Throat [ ] Yes [ ] No

Purpose of Visit to ESNCHS: Purpose of Visit to ESSU:

_______________________________________ _______________________________________
_______________________________________ _______________________________________

HEALTH DECLARATION FORM

Date: _____________ Time: ____________
Personal Information:
Name: ______________________________
Age: _______ Sex: __________
Address:
__________________________________
Contact# ____________________________

Current Health Condition:

Fever [ ] Yes [ ] No - temp. ___ºc
Cough [ ] Yes [ ] No
Colds [ ] Yes [ ] No
Sore Throat [ ] Yes [ ] No

Purpose of Visit to ESSU:

_______________________________________
_______________________________________
 HEALTH DECLARATION FORM
Date: _____________ Time: ____________
Personal Information:
Name: ______________________________
Age: _______ Sex: __________
Address:
__________________________________
Contact# ____________________________

Current Health Condition:

Fever [ ] Yes [ ] No - temp. ___ºc
Cough [ ] Yes [ ] No
Colds [ ] Yes [ ] No
Sore Throat [ ] Yes [ ] No

Purpose of Visit to ESSU:

_______________________________________
_______________________________________