Health Survey

Name : Sex : Age :

Position : Jobsite:
Permanent Address :
Quarantine Location :

Please respond to the following questions by placing a check (✔) in the asnwer box that correspond to
your response and/or fill in the blank where indicated.
1. Are you experiencing:
(nakakaranas ka ba ng:)
2. Medical History
YES NO
a. Sore Throat
(pananakit ng lalamunan/masakit lumunok)
b. Body Pain
(pananakit ng katawan)
c. Headache
(pananakit ng ulo)
d. Fever for the past few days
(lagnat sa mga nakalipas na araw)
e. Breathlessness
(hirap sa paghinga)
f. Chest Pain
(pananakit ng dibdib)
g. Abnormal Taste and Smell
(di normal na panlasa at pang amoy)
a. Highblood Pressure
b. Diabetes
c. Respiratory Diseases
d. Body Temperature (*** ˚C, measured at***)

3. Have you Stayed in the same close environment of a confirmed COVID-19 case?
(May nakasama o nakasalamuha ka ba na nagpositibo sa COVID-19 o coronavirus?)
4. Did you have any medical treatment at a medical institution?
(Ikaw ba ay sumailalam sa gamutan sa isang ospital?)
5. Was there any coronavirus infection in your neighborhood?
(Mayroon bang naging kaso ng coronavirus sa inyong lugar?
6. Did you stay with the person with PUM or PUI?
(May naksama ka bang tao na nag-PUM o PUI?)
7. Does anyone in your household have the potential to come into contact with someone
infected with coronavirus? For example, doctor, nurses, hospital staff working at
medical institutions.
(Mayroon bang posilibilidad na makipag-ugnay sa sinumang may impeksyon sa coronavirus ang
inyong kasama sa bahay? Halimbawa ay doktor,nars, kawani ng ospital na nagtatrabaho sa mga
institusyong medikal.)
8. Have you travelled to any area Metro Manila aside from your home?
(Ikaw ba ay nagbiyahe sa ibang parte ng Metro Manila bukod sa iyong bahay?)
Specify (sabihin kung saan:)
I hereby authorize Mako Teknomecaniques, Inc. to collect and process the data indicated herein for the purpose of affecting
control of the COVID-19 infection. I understand that my personal information is protected by RA 10173, Data Privacy
Act of 2020 that I am requiredby RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

Signature : Date :
 Health Survey

pose of affecting
Data Privacy