Republic of the Philippines

Department of Health

PROFILE OF THE COVID-19 CLOSE CONTACTS

Use black or blue pen only. Write clearly in BLOCK letters. Place in all applicable boxes.
DEMOGRAPHIC PROFILE
NAME:
___________________________________________________________________ NATIONALITY: ___________________
Last Name Given Name Middle
AGE:______________ SEX: Male Female Pregnant Trimester: ___________________
DATE OF BIRTH:
_________________________ CIVIL STATUS: _________________ RELIGION: ___________________
MM / DD / YYYY
HOME ADDRESS: _______________________________________________________________________________________
House No. , Bldg. No. , Street Name Barangay Mun/City Province Region
CONTACT DETAILS: _____________________ ___________________ EMAIL ADDRESS:
Home Telephone Number Mobile Number _________________________
Confirmed Case ID: ________________________________ Date of Onset of Illness (mm/dd/yyyy): ___________________

HEALTH PROFILE

KNOWN MEDICAL CONDITIONS AND MEDICAL HISTORY:

_____________________________________________________________________________________
_____________________________________________________________________________________
CURRENT MEDICATIONS: BLOOD TYPE:
_________________________________________________________________ ________________________________

NATURE OF EXPOSURE (Select All that Applies)

Plane Airline: ____________________ Flight No.: ________ Route: ___________ Date of Last Exposure: ___/___/____
Crew Passenger Seat No.: __________ Within 4-rows: Yes No If crew: In-flight Ground

Sea Vessel Name of Sea Vessel: ______________________ Vessel No.: ______________ Route: _____________
Date of Last Exposure: ___ / ___ / _____ Crew Passenger Seat No.: _________ Within 4-rows: Yes No
If crew: In-flight Ground

Land Vehicle Specify type: _________________ Route: ______________ Date of Last Exposure: ____/____/____
Crew Passenger Seat No.: _______ Within 4-rows: Yes No If crew: Driver Conductor

Accommodation Specify type: _____________ Name: _______________________ Date of Last Exposure: ____/____/____
Address: _____________________________________________________ Guest Hotel worker: ____________
Mun/City Province Region

Food Establishment Specify type: _______________ Name: ______________________ Date of Last Exposure: ___/___/___
Address: ___________________________________________________ Diner Crew: _______________
Mun/City Province Region

Health Facility Specify type: _________________ Name: ____________________ Date of Last Exposure: ____/____/____
Address: __________________________________________________ Patient Health worker: _____________
Mun/City Province Region If health worker, fill-out assessment of risk of exposure WHO form

Event Specify type: ______________ Event Place: ________________________ Date of Last Exposure: ____/____/____

Workplace Company Name: _________________ Address: __________________________________________________

Date of Last Exposure: ____/____/____ Mun/City Province Region

<Health Status Assessment on Page 2>

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Symptomatic (Fever or Respiratory Infection or Diarrhea): A 14 days prior to first date of exposure
B. Anytime during date of exposure

Date Onset of illness:__/__/___

Select all that applies:

Yes No Attendance in social events/ gatherings within two weeks from onset of illness
If yes, where: ___________________________ Date: ___/___/_____
Yes No Travelled outside the province within two weeks from onset of illness
If yes, where: ___________________ From Date: ___/___/___ - To Date: ___/___/___
Yes No Travelled outside the country within two weeks from onset of illness
If yes, where: ___________________ From Date: ___/___/___ - To Date: ___/___/___

Symptomatic within 12 days after last date of exposure: Yes No

If yes, Date onset of illness: ___/___/___ Name of Referral Hospital: _____________________

If no, Place of Quarantine: Home Quarantine Facility, specify: _______________________

Assessed by: ___________________________ Date Assessed: ___/___/___

(Name and Signature)

<Proceed to fill-out COVID-19 Contact Tracing Sign and Symptoms Log Form>