HEALTH CHECKLIST

Employee Name: ___________________________ Department: _________________ Visitor: ___________ Company: ____________ Sex: _______ Age: ________
Residence: ____________________________________________ Temperature: ________ Date: __________ Time: ___________
Nature of Visit: Please check one ( ) Official ( ) Personal
If official, fill-in company details below________________ Company Name _______________________ Company Address ________________ Person to visit: _____

 Are you experiencing:

(nakakaranas ka ba ng)
 Sore Throat YES ____ NO
____
( pananakit ng lalamunan/masakit lumunok)
 Body Pains YES ____ NO
____
(pananakit ng katawan)
 Headache YES ____ NO
____
(pananakit ng ulo)
 Fever for the past few days YES ____ NO
____
(Lagnat sa nakalipas na mga araw)
 Cogh/Colds YES ____ NO
____
(inuubo/sinisipon)
 Difficulty in Breathing YES ____ NO ____
(nahihirapan sa paghinga)
 Have you worked together or stayed in the same close YES ____ NO
____
environment of a confirmed COVID-19 case?
(May nakasama o nakatrabahong tao na kumpirmadong may COVID-19/ may impeksyon ng coronavirus?)
 Have you had any contact with anyone with fever, cough, colds, YES ____ NO ____
sore throat in the past 2 weeks?
(May nakasam ka ba na may lagnat, ubo, sipon o masakit ang lalamunan sa nakaraang dalawang lingo?)
 Have you travelled outside of the Philippines in the last 14 days? YES ____ NO ____
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas ng 14 ng araw?)
 Have you travelled to any other area (city/town) in (name of province) aside from your home in the last 14 days? YES ____ NO ____
If yes, specify where _____________________________________
Ikaw ba ay ay nagbiyahe sa ibang lungsod/bayan sa probinsya ng ( ______________ ) maliban sainyong tahanan sa nakaraang 14 na araw?
Kung Oo, saan ___________________________________
 Note: I hereby grant my express, unconditional, voluntary, and informed consent to and hereby authorize The SM _________ to collect my personal and needed
information for the purpose of profiling. I hereby knowingly and voluntary acknowledge and confirm that I have been duly informed on my rights under the law
with respect to my personal and health information. I hereby confirm that I have executed the same of my own volition and free will.

_________________________________
HEALTH
Signature on topCHECKLIST
of Printed Name

Employee Name: ___________________________ Department: _________________ Visitor: ___________ Company: ____________ Sex: _______ Age: ________
Residence: ____________________________________________ Temperature: ________ Date: __________ Time: ___________
Nature of Visit: Please check one ( ) Official ( ) Personal
If official, fill-in company details below________________ Company Name _______________________ Company Address ________________ Person to visit: _____

 Are you experiencing:

(nakakaranas ka ba ng)
 Sore Throat YES ____ NO
____
( pananakit ng lalamunan/masakit lumunok)
 Body Pains YES ____ NO
____
(pananakit ng katawan)
 Headache YES ____ NO
____
(pananakit ng ulo)
 Fever for the past few days YES ____ NO
____
(Lagnat sa nakalipas na mga araw)
 Cogh/Colds YES ____ NO
____
(inuubo/sinisipon)
 Difficulty in Breathing YES ____ NO ____
(nahihirapan sa paghinga)
 Have you worked together or stayed in the same close YES ____ NO
____
environment of a confirmed COVID-19 case?
(May nakasama o nakatrabahong tao na kumpirmadong may COVID-19/ may impeksyon ng coronavirus?)
 Have you had any contact with anyone with fever, cough, colds, YES ____ NO ____
sore throat in the past 2 weeks?
(May nakasam ka ba na may lagnat, ubo, sipon o masakit ang lalamunan sa nakaraang dalawang lingo?)
 Have you travelled outside of the Philippines in the last 14 days? YES ____ NO ____
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas ng 14 ng araw?)
 Have you travelled to any other area (city/town) in (name of province) aside from your home in the last 14 days? YES ____ NO ____
If yes, specify where _____________________________________
Ikaw ba ay ay nagbiyahe sa ibang lungsod/bayan sa probinsya ng ( ______________ ) maliban sainyong tahanan sa nakaraang 14 na araw?
Kung Oo, saan ___________________________________

Note: I hereby grant my express, unconditional, voluntary, and informed consent to and hereby authorize The SM _________ to collect my personal and needed
information for the purpose of profiling. I hereby knowingly and voluntary acknowledge and confirm that I have been duly informed on my rights under the law
with respect to my personal and health information. I hereby confirm that I have executed the same of my own volition and free will.

_________________________________
Signature on top of Printed Name