SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART

Assumption Road, Baguio City

“We Truly Care”

COVID-19 SCREENING TOOL

To protect everyone at this facility- patients, staff and visitors- we are asking all visitors to
complete the following questionnaire.
Name___________________________________ Age_____ Gender_____ Contact Number_________________
Address____________________________________________________
Have you in the last 14 days:
o Traveled outside Baguio
o YES (Where and Date):
o NO
o Traveled abroad? Where?
o YES (Where and Date):
o NO
o Been in contact with a novel coronavirus (COVID-19) infected person
o YES (Where and Date):
o NO
o Been in contact with anyone who has recently traveled especially to countries or areas
within the Philippines with confirmed COVID-19 cases?
o YES (Where and Date):
o NO
o Have you had the following symptoms in the last few days:
o ____Fever o ____Difficulty of breathing/
o ____Cough Shortness of breath
o ____Colds o ____Diarrhea
o ____Body aches/pain o ____Headache
o ____Sore Throat
DECLARATION

I hereby declare that I have read and fully understood the above provisions of law. Also, I
certify that the information given are true, correct and complete. I understand that failure to
answer or any false/wrong information given may be a ground for filing of a criminal case
against me under the above law (Ako ay nagpapatunay na ang mga impormasyon na aking
ibinigay ay totoo, tama at kumpleto. Naiintindihan ko na ang kabiguang sumagot o anumang
maling impormasyon ay maaaring maging dahilan para sa paghain ng kasong criminal laban
sa akin sa ilalim ng batas)

Patient:_______________________________________________________________
NAME(PANGALAN/ SIGNATURE(LAGDA)
ADDRESS:______________________________________________________________
DATE(PETSA)__________________
TIME(ORAS)___________________
Watcher:______________________________________________________________
NAME(PANGALAN/ SIGNATURE(LAGDA)
ADDRESS:______________________________________________________________
DATE(PETSA)__________________
TIME(ORAS)___________________