PHILIPPINE DENTAL ASSOCIATION INC.

AYALA AVENUE corner KAMAGONG STREET, SAN ANTONIO VILLAGE TELEPHONE: (632) 890-4609
MAKATI CITY, METRO MANILA, PHILIPPINES 1203 (632) 897-8091
Website: www.pda.ph Email: pdao ce1908@gmail.com FACSIMILE: (632) 899-6332

Philippine Dental Association Covid 19 Monitoring Form

This form is made exclusively for Den st who have undergone a covid 19 test (Rapid Test or Swab Test) and was
con rmed posi ve to SARS-COV 2 virus. The data to be collected shall be used strictly to help monitor the number
of den sts a icted and likewise help the associa on create policies and recommenda ons to the government in
the interest of public health.
We are hoping for your full coopera on to answer the ques ons as truthful and complete as you can. Rest assured
that we would treat the data with strict con den ality.

A : Patient Information
Aaron Paul D. Bernas
Name of Pa ent: ____________________________________
September 21, 1985
Birth Date: _____________________________Sex: Male
___________Status: Married
_______________________________
12A Magsaysay St. Salvacion Bayombong Nueva
Home Address:__________________________________Clinic Bayombong, Nueva Vizcaya
Address:________________________________
Vizcaya
09688823882
Contact Number: _________________________Email Address: ______________________________________
Landbank
Bank Acct. Name (preferably den st acct.): ______________________Bank Name/Acct. No: 0436323093
_______________
HMO: __________________________________ Expira on Date: _____________________________________
PRC Number: ____________________________Chapter
0050317 A lia on: ___________________________________
NVIDC

B: Covid Tracing
Type of Test:
_____________RT-PCR
POSITIVE Swab Test POSITIVE
_______________ RT-PCR Saliva Test
Date of Test: _________________
01/27/2022 Name of Laboratory _____________________________________________
Isabela Molecular Laboratory
History of Exposure: Dental Clinic Hospital Household
________Pa ent ______ as in-pa ent _______Husband/Wife
________Assistant/Secretary ______ as out-pa ent _______Children
________ Associate Den st _______Household Help
Other Sources___________________________________________________
B
Blood Type __________________________ 120/80
Blood Pressure __________________________
Symptoms Experienced: Asymptoma c __________ Mild _________ Moderate _________ Severe__________
Symptoms:
______ headache ______ cough ______ colds ________di culty of breathing
______ fever/chill ______ loss of smell ______ sore throat ________nausea or vomi ng
______ chest pain ______ loss of appe te ______ fa gue ________high blood pressure
______ confusion ______ muscle pain ______ diarrhea ________low blood pressure
Other symptoms: ___________________________________________________________________________

C: Past Medical History

1. Have you or any members of your household travelled to any areas with known cases of COVID 19?
none
(state the exact loca on) ______________________________________________________________________
2. Any other member of your household who tested COVID 19 posi ve? __________________________
yes, my wife
no
3. Have you been tested COVID 19 posi ve before? ___________________________________________
4. Are you under medical treatment now? If so, what is the condi on being treated?
no
___________________________________________________________________________________
5. Have you ever been hospitalized? If so, when and why?
no
___________________________________________________________________________________
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 PHILIPPINE DENTAL ASSOCIATION INC.
AYALA AVENUE corner KAMAGONG STREET, SAN ANTONIO VILLAGE TELEPHONE: (632) 890-4609
MAKATI CITY, METRO MANILA, PHILIPPINES 1203 (632) 897-8091
Website: www.pda.ph Email: pdao ce1908@gmail.com FACSIMILE: (632) 899-6332

6. Have you ever had serious illness or surgical opera on? If so, what illness or opera on?
no
___________________________________________________________________________________

7. Are you taking any prescrip on/non-prescrip on medica on? If so, please specify.

none
___________________________________________________________________________________

8. Have you been vaccinated? 1st Dose ______________ 2nd Dose ___________________________

9. Do you have or have you had any of the following? Check which apply

______stroke ______diabetes ______chest pain ______tuberculosis

______asthma ______heart a ack ______heart surgery ______Thyroid problem
______angina ______anemia ______cancer/tumor ______Emphysema
______kidney disease ______heart disease _______ heart murmur ______hepa/liver disease
______epilepsy ______AIDS/HIV infec on _______STD ______Ulcer
______fain ng seizure _____rapid weight loss _______radia on therapy ______joint replacement/implant
______rheuma c fever _____hay fever/allergies _______respiratory problem ______hepa s/jaundice
______swollen ankles _____blood disease _______heart injuries ______bleeding problem
______arthri s/rheuma sm

Other symptoms: ___________________________________________________________________________

For Women only:

Are you pregnant? ___________________ Are you nursing? ________________________

Any other informa on you wish to reveal that would help us in our data gathering?
none
__________________________________________________________________________________________

Aaron Paul D. Bernas

________________________________ _________________________________
(printed name & signature of pa ent) (printed name & signature of authorized
representa ve

Kindly forward this document along with an a ached photocopy of the 1. covid 19 test result/s, 2. photocopy of
PRC ID to this email address pdacovidmonitoring@gmail.com or get in touch with the commi ee through mobile
number 09175349057. (Please be informed that availment of the covid assistance fund from the PDA requires full
disclosure of this document and upon the assessment of the commi ee)
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 PHILIPPINE DENTAL ASSOCIATION INC.
AYALA AVENUE corner KAMAGONG STREET, SAN ANTONIO VILLAGE TELEPHONE: (632) 890-4609
MAKATI CITY, METRO MANILA, PHILIPPINES 1203 (632) 897-8091
Website: www.pda.ph Email: pdao ce1908@gmail.com FACSIMILE: (632) 899-6332

_________________,
Feb 10 20____
22
(dated)

CONSENT FORM:

I confirm that I have read and understand the PDA COVID 19 monitoring form.

I am TRUTHFULLY answering the questionnaire and upon submitting this form I am

giving consent to the PDA COVID 19 monitoring committee to access my records/information
that may be relevant for statistics and/or research to improve the welfare of all dentists and uplift
the practice of dentistry.

I also understand that my personal information will remain confidential. Any questions
regarding this consent can be addressed to me through my email address or mobile number.

Sincerely,

Aaron Paul D. Bernas

___________________________________
(Dentist Name and Signature)
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