HEALTH DECLARATION FORM HEALTH DECLARATION FORM

NAME:____________________________________________________AGE:______ NAME:____________________________________________________AGE:______
ADDRESS:_________________________________________________SEX:_______ ADDRESS:_________________________________________________SEX:_______
___EMPLOYEE (Unit) ___________ CP/TEL. NO.:________________ ___EMPLOYEE (Unit) ___________ CP/TEL. NO.:________________
___STUDENT (College) __________ ___STUDENT (College) __________
___VISITOR ___VISITOR

PLEASE ANSWER THE QUESTIONS HONESTLY. PLEASE ANSWER THE QUESTIONS HONESTLY.
CHECK (/) YOUR ANSWER. CHECK (/) YOUR ANSWER.

Do you have any of these symptoms within the 14 days period? Do you have any of these symptoms within the 14 days period?
SYMPTOMS YES NO SYMPTOMS YES NO SYMPTOMS YES NO SYMPTOMS YES NO
FEVER DIARRHEA FEVER DIARRHEA
COUGH SORE THROAT COUGH SORE THROAT
COLDS DIFFICULTY OF BREATHING COLDS DIFFICULTY OF BREATHING
NO SENSE OF SMELL MUSCLE & JOINT PAIN NO SENSE OF SMELL MUSCLE & JOINT PAIN

OTHER INFORMATION: OTHER INFORMATION:

YES NO YES NO
HISTORY OF TRAVEL/VISIT FROM ANY PLACE OUTSIDE ILOCOS NORTE? HISTORY OF TRAVEL/VISIT FROM ANY PLACE OUTSIDE ILOCOS NORTE?
IF YES, WHERE? WHEN? IF YES, WHERE? WHEN?
VISITORS/RELATIVES THAT COME FROM OTHER PLACE? VISITORS/RELATIVES THAT COME FROM OTHER PLACE?
IF YES, WHERE? WHEN? IF YES, WHERE? WHEN?
EXPOSURE TO ANYONE WITH SYMPTOMS OF FEVER, COUGH, COLDS EXPOSURE TO ANYONE WITH SYMPTOMS OF FEVER, COUGH, COLDS
OR DIARRHEA IN YOUR HOME, WORK, SCHOOL, OR ANY GATHERINGS OR DIARRHEA IN YOUR HOME, WORK, SCHOOL, OR ANY GATHERINGS
(BITHDAY, WAKES, FIESTA, ETC.)? (BITHDAY, WAKES, FIESTA, ETC.)?
TAKING CARE OF RELATIVE/PATIENT AT HOME WITH SYMPTOMS OF TAKING CARE OF RELATIVE/PATIENT AT HOME WITH SYMPTOMS OF
FEVER, COUGH, COLDS OR DIARRHEA? FEVER, COUGH, COLDS OR DIARRHEA?
VISITED/MONITORED BY BARANGAY HEALTH WORKERS/OFFICIALS? VISITED/MONITORED BY BARANGAY HEALTH WORKERS/OFFICIALS?

DECLARATION: DECLARATION:

I hereby certify that all information is true and complete. I do understand that I hereby certify that all information is true and complete. I do understand that
any false/wrong information can be used by the court against me under Article 161 any false/wrong information can be used by the court against me under Article 161
of the Revised Penal Code of the Philippines, RA 11332 “Law on Reporting of the Revised Penal Code of the Philippines, RA 11332 “Law on Reporting
Communicable Diseases”. Communicable Diseases”.

__________________________ _____________ __________________________ _____________

Signature Date Signature Date