Republic of the Philippines

Department of Health

PROFILE OF THE COVID-19 CLOSE CONTACTS

Use black or blue pen only. Write clearly in BLOCK letters. Place X in all applicable boxes.

DEMOGRAPHIC PROFILE

NAME: _____________________________________________________ NATIONALITY: _________________

Last Name Given Name Middle Name

AGE: __________ SEX: Male Female Pregnant Trimester: ___________________________

DATE OF BIRTH: __________________ CIVIL STATUS: _______________ RELIGION: _________________

MM / DD / YYYY

HOME ADDRESS: __________________________________________________________________________

House No., Bldg. No., Street Name Barangay MunCity Province Region

CONTACT DETAILS: ___________________ _________________ EMAIL ADDRESS: _______________________

Home Telephone No. Mobile No.

Confirmed Case ID: ___________________________ Date of Onset of Illness (mm/dd/yyy): _____________________

HEALTH PROFILE
KNOWN MEDICAL CONDITION/S AND MEDICAL HISTORY:
___________________________________________________________________________________________
____________________________________________________________________________
CURRENT MEDICATION/S: BLOOD TYPE:

___________________________________________________________________ ___________________

NATURE OF EXPOSURE (Select All That Applies)

Plane Airline:___________ Flight No.:__________ Route:_____________ Date of Last Exposure: ___/___/____

Crew Passenger Seat No.: ________ Within 4-rows: Yes No If crew: In-flight Ground

Sea Vessel Name of Sea Vessel:___________ Vessel No.:__________ Route:___________

Date of Last Exposure: ___/___/____ Crew Passenger Seat No.: ________ Within 4-rows: Yes No
If crew: In-flight Ground

Land Vehicle Specify type:___________ Route:_____________ Date of Last Exposure: ___/___/____

Crew Passenger Seat No.: ________ Within 4-rows: Yes No If crew: Driver Conductor

Accommodation Specify type:___________ Name:_____________________ Date of Last Exposure: ___/___/____

Address: ______________________________________________ Guest Hotel worker: ______________
MunCity Province Region

Food Establishment Specify type:___________ Name:__________________ Date of Last Exposure: ___/___/____

Address: ______________________________________________ Diner Crew: ______________
MunCity Province Region

Store Specify type:___________ Name:______________________________ Date of Last Exposure: ___/___/____

Address: ______________________________________________ Customer Worker: ______________
MunCity Province Region

Health Facility Specify type:___________ Name:______________________ Date of Last Exposure: ___/___/____

Address: ____________________________________________ Patient Health Worker: ________________
MunCity Province Region If health worker, fill-out assessment of risk of exposure WHO form

Event Specify type:___________ Event place:_________________________ Date of Last Exposure: ___/___/____

Workplace Company Name:_______________________ Address: ____________________________________
MunCity Province Region
Date of Last Exposure: ___/___/____

<Health Status Assessment on Page 2>

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Symptomatic (Fever or Respiratory Infection or Diarrhea): A. 14 days prior to first date of exposure
B. Anytime during date of exposure

Date Onset of Illness: ___/___/____

Select all that applies:

Yes No Attendance in social events/ gatherings within two weeks from onset of illness
If yes, where: _______________________ Date: ___/___/____

Yes No Travelled outside the province within two weeks from onset of illness
If yes, where: _______________________ From Date: ___/___/____ - To Date: ___/___/____

Yes No Travelled outside the country within two weeks from onset of illness
If yes, where: _______________________ From Date: ___/___/____ - To Date: ___/___/____

Symptomatic within 14 days after last date of exposure: Yes No

If yes, Date Onset of Illness: ___/___/____ Name of Referral Hospital:___________________________

Date of Referral: ___/___/____

If no, Place of Quarantine: Home Quarantine Facility, specify: ______________________________

Assessed by: ____________________________________ Date Assessed: ___/___/____

(Name and Signature)

<Proceed to Fill-out COVID-19 Contact Tracing Sign and Symptom Log Form>

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