HEALTH DECLARATION FORM

PLEASE FILL OUT THIS FORM.

NAME _____________________________________________________________________________________
Last First MI
HOME ADDRESS
AGE: (60 y/o & above are not allowed to enter) GENDER OCCUPATION
CONTACT NO. E-MAIL ADDRESS DEPARTMENT
POINT OF ORIGIN (PINANGGALINGANG LUGAR):
PLACE OF DESTINATION IN BAGUIO CITY (LUGAR NA PUPUNTAHAN/TUTULUYAN SA BAGUIO CITY):

EXPOSURE HISTORY:
1. Where did you live in the past two weeks? Kindly write complete address. (If the employee had resided in multiple areas,
write complete address of all areas indicating exact dates of residence.)_________________________________________
Is/Are this/these area/s included in the list of areas with confirmed COVID-19 cases? ( ) YES ( ) NO
DATE: Fill out each column with the dates, when you will
enter SLU.
Temperature: (to be taken by the healthcare workers)
INSTRUCTION: Answer the following questions with Yes or No.
Please tick or check ( / ) your answers on the column base on the date.
2. In the past two weeks, have you:
YES NO YES NO YES NO YES NO YES NO
a. Provided direct care for a lab-confirmed COVID-19 patient? ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
b. Worked before of stayed in the same close environment as a ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
COVID -19 patient?
c. Traveled together with a lab-confirmed COVID-19 patient in any ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
kind of vehicle or conveyance?
d. Lived in the same household as a lab-confirmed COVID-19 ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
patient?
3. Have you worked, visited, transited, or traveled in a foreign YES NO YES NO YES NO YES NO YES NO
country in the last 14 days? ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
4. CONTACT HISTORY:
Have you ever lived with, cared for, or had direct contact with a YES NO YES NO YES NO YES NO YES NO
suspect (PUI) or confirmed case of COVID-19? ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
5. MEDICAL HISTORY:
Have you been sick or experienced any of the following in the
last 14 days?
(Nagkasakit ka ba sa mga sumusunod sa nakaraang 14 na araw?)
YES NO YES NO YES NO YES NO YES NO
SICKNESS (KARAMDAMAN)
- FEVER (LAGNAT) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
- COUGH (UBO) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
- COLDS (SIPON) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
- SORE THROAT (PANANAKIT NG LALAMUNAN) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
- DIFFICULTY IN BREATHING (HIRAP SA PAGHINGA) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
- DIARRHEA (MADALA NA PAGDUMI) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
OTHERS: Do you have history of Hypertension, Diabetes Mellitus, Heart ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
disease, Lung Disease etc. Others please write it on the space provided. _______ _______ _______ _______ _______
DECLARATION: I hereby certify that the above information is true and complete.
I understand that my failure to answer, or any false or misleading information given
by me may be used as a ground for the filing of cases against me under Articles 171
and 172 of the Revised Penal Code of the Philippines, or Republic Act No. 11332,
otherwise known as the “Law on Reporting of Communicable Disease”. (Ako ay _______ _______ _______ _______ _______
nagpapatunay na ang mga impormasyon na aking binigay ay totoo at kumpleto. SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE
Naiintindihan ko na ang kung anumang maling impormasyon ay maaring maging
dahilan para sa paghain ng kasong criminal laban sa akin sa ilalalim ng Article 171 at
172 ng Revised Penal Code o sa ilalim ng Republic Act No. 11332).

ACTIONS TO BE DONE
(TO BE FILLED UP BY THE TRIAGE OFFICER)
NAME AND SIGNATURE OF TRIAGE OFFICER

PLEASE SUBMIT THIS FORM TO THE MEDICAL CLINIC ONCE ALL THE COLUMNS ARE FILLED OUT.
* As a precautionary measure by the City of Baguio against the transmission of COVID-19, pursuant to Proclamation No. 922, dated 8 March 2020, and the Section
16 of the Local Government Code.
* ALL EMPLOYEES, OR VISITORS ENTERING SLU PREMISES WITH RESPIRATORY SYMPTOMS, FEVER, EXPOSURE OR HAVE CLOSE CONTACT WITH A POSITIVE COVID-19 CASE ARE NOT ALLOWED TO ENTER . THIS
WILL BE LIFTED DEPENDING ON THE FUTURE HEALTH SITUATION.