Republic of the Philippines
Department of Education
Region III
SCHOOLS DIVISION OF ZAMBALES
Iba, Zambales
Tel./Fax No. (047) 602 1391 / (047) 307 2076
E-mail Address: zambales@deped.gov.ph
website: www.depedzambales.ph
Health Form
Name:________________________________
Age: ____________ Sex: ___________
Address: ___________________________________________________
Contact No.: _______________________________________________
Date:
1. Temperature: _________________________________________
2. Have the ff. symptoms in the past 14 days:
a. Fever: ________________________________________
b. Cough: _______________________________________
c. Colds: ________________________________________
d. Shortness of Breath: __________________________
e. Difficulty of Breathing: _________________________
f. Sore throat: _________________________________
3. Have exposure to suspected or confirmed COVID-19
case for the past 14 days : YES ________ No: _________
If yes, what is your relationship to the patient:
_____________________________________________________
_____________________________________________________
4. Have travel history outside the province in the past 14
days: YES ________ No: _________
If yes, where?
_____________________________________________________
_____________________________________________________
_____________________________________________
Name and Signature
Republic of the Philippines
Department of Education
Region III
SCHOOLS DIVISION OF ZAMBALES
Iba, Zambales
Tel./Fax No. (047) 602 1391 / (047) 307 2076
E-mail Address: zambales@deped.gov.ph
website: www.depedzambales.ph
Health Form
Name:________________________________
Age: ____________ Sex: ___________
Address: ___________________________________________________
Contact No.: _______________________________________________
Date:
1. Temperature: _________________________________________
2. Have the ff. symptoms in the past 14 days:
a. Fever: ________________________________________
b. Cough: _______________________________________
c. Colds: ________________________________________
d. Shortness of Breath: __________________________
e. Difficulty of Breathing: _________________________
f. Sore throat: _________________________________
3. Have exposure to suspected or confirmed COVID-19
case for the past 14 days : YES ________ No: _________
If yes, what is your relationship to the patient:
_____________________________________________________
_____________________________________________________
4. Have travel history outside the province in the past 14
days: YES ________ No: _________
If yes, where?
_____________________________________________________
_____________________________________________________
_____________________________________________
Name and Signature
Republic of the Philippines
Department of Education
Region III
SCHOOLS DIVISION OF ZAMBALES
Iba, Zambales
Tel./Fax No. (047) 602 1391 / (047) 307 2076
E-mail Address: zambales@deped.gov.ph
website: www.depedzambales.ph
Health Form
Name:________________________________
Age: ____________ Sex: ___________
Address: ___________________________________________________
Contact No.: _______________________________________________
Date:
1. Temperature: _________________________________________
2. Have the ff. symptoms in the past 14 days:
a. Fever: ________________________________________
b. Cough: _______________________________________
c. Colds: ________________________________________
d. Shortness of Breath: __________________________
e. Difficulty of Breathing: _________________________
f. Sore throat: _________________________________
3. Have exposure to suspected or confirmed COVID-19
case for the past 14 days : YES ________ No: _________
If yes, what is your relationship to the patient:
_____________________________________________________
_____________________________________________________
4. Have travel history outside the province in the past 14
days: YES ________ No: _________
If yes, where?
_____________________________________________________
_____________________________________________________
_____________________________________________
Name and Signature
Republic of the Philippines
Department of Education
Region III
SCHOOLS DIVISION OF ZAMBALES
Iba, Zambales
Tel./Fax No. (047) 602 1391 / (047) 307 2076
E-mail Address: zambales@deped.gov.ph
website: www.depedzambales.ph
Health Form
Name:________________________________
Age: ____________ Sex: ___________
Address: ___________________________________________________
Contact No.: _______________________________________________
Date:
1. Temperature: _________________________________________
2. Have the ff. symptoms in the past 14 days:
a. Fever: ________________________________________
b. Cough: _______________________________________
c. Colds: ________________________________________
d. Shortness of Breath: __________________________
e. Difficulty of Breathing: _________________________
f. Sore throat: _________________________________
3. Have exposure to suspected or confirmed COVID-19
case for the past 14 days : YES ________ No: _________
If yes, what is your relationship to the patient:
_____________________________________________________
_____________________________________________________
4. Have travel history outside the province in the past 14
days: YES ________ No: _________
If yes, where?
_____________________________________________________
_____________________________________________________
_____________________________________________
Name and Signature