Republic of the Philippines

Department of Interior and Local Government

BUREAU OF FIRE PROTECTION
REGIONAL OFFICE 1
Patac, Sto. Tomas, La Union

HEALTH SURVEY FORM

(All information provided herein will not be disclosed to anyone and shall be covered by DATA
PRIVACY ACT of 2012 unless authorized by law.)

a. Do you have the following?

(Mayroon ka ba ng mga sumusunod?)

YES NO
1. Fever (Lagnat) □ □
≥ 37.6 ‫﮲‬C
2. Coughs and/or Colds □ □
(Lagnat at/o Ubo)

b.For the past 14 days (Sa nakalipas na 14 na araw):

Ikaw ba ay:

1. Have travel history to other countries

(Nanggaling sa ibang bansa?)
a. Where? (Saan?) ________________________
b. When? (Kailan?) ________________________
c. Date of Arrival__________________________

2. Have travel history to areas with positive/active COVID-19 case?

(Nanggaling sa lugar na may positibo/aktibong kaso ng COVID-19?)
a. Where? (Saan?) ________________________
b. When? (Kailan?) ________________________
c. Date of Arrival__________________________

3. History of contact with a confirmed COVID-19 patient or visited a hospital with a confirmed COVID-19
patient?
(Nakisalamuha sa pasyente na may kumprimadong COVID-19 o bumisita sa hospital na may kumprimadong
COVID -19 na pasyente?
□ YES □ NO DATE ______________

I CERTIFY THAT THE ABOVE INFORMATION GIVEN ARE TRUE AND CORRECT AS TO THE
BEST OF MY KNOWLEDGE.

____________________________
Signature over Printed Name

Address: ____________________________
Contact Number: ______________________
Date: __________________