CVD-MR-001

COVID-19 HEALTH CHECKLIST Rev.001

Name:________________________

Date:__________________________

Purpose of Visit: Temperature:

Questions YES NO
1. Do you have some of the following symptoms:
 Cough and fever for the past few days

 Headache and Dizziness

 Sore Throat

 Body Pain

 Difficulty in breathing

 Have diarrhea

2. Do you have a close contact or direct contact with the

person who has the following symptoms in the past two
weeks?
3. Do you have a close contact or direct contact to a
positive covid-19 patient?
4. Have you travelled international for the past 14 days?

5. Have you travelled around NCR, Bulacan, Nueva Ecija

Zambales, Bataan and Region 7 for the past 14 days?

Note: Please be honest with your answers, this is in line with the controlling of spread of
COVID-19 infection. Please be informed that the following collected data will be
confidential. Thank you for your consideration.

Signature and Date: