Republic of the Philippines

Province of Cavite
OFFICE OF THE CITY HEALTH
TRECE MARTIRES CITY, CAVITE

COVID-19 SYMPTOMS LOGSHEET

BARANGAY:
PUI CLOSED CONTACT POSITIVE
NAME/AGE/SEX: START DATE OF MONITORING: REGION: IVA
ADDRESS: END DATE OF VOLUNTARY MONITORING:
DATE OF ARRIVAL IN THE PHILIPPINES: DATE OF LAST EXPOSURE (IF CASE HAS A HX OF EXPOSURE):

SYMPTOMS DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE
10TH DAY 14TH DAY
No Symptoms
Fever (Temperature )
Cough
Colds
Sore Throat
Took Antivirals
Other Symptoms:
1.
2
3.
4.
5.
Sought Consult

BIRTHDAY: PREGNANT/LMP/EDC:
CIVIL STATUS: CXR/WHEN/RESULT:
NATIONALITY: DATE OF ONSET OF ILLNESS:
OCCUPATION/COMPANY: S/SX/COMORBIDITY:
PLACE OF WORK: SWAB TEST DONE:
PHILHEALTH ID: RELEASE DATE:
CONTACT NO.:

FULLY VACCINATED? YES NO DATE OF 1ST DOSE: DATE OF 2ND DOSE: BOOSTER: VACCINE BRAND: FACILITY:

BARANGAY HEALTH NURSE / MIDWIFE CONTACT TRACER/BHW