PHILIPPINE AIR FORCE ‘520TH AIR BASE WING ‘AIR FORCE GENERAL HOSPITAL Colonel iesus Vilamor Air Base, Pacay City (COVID-19 HEALTH DECLARATION FORE asec [== aT poor Sacra ‘aioe ‘BRIEF START OF QUARANTINE nee OF oma esa TF 1L ave you worked or wsted,rensited or traveled to other placea/| [_] Yeu Goca/forian)wherer countries for the past 14 days? On 2. Have you visited places of postive COWD-a9? Elwes No 7 Have youbeen n close contact wah person whois. Suspea, Yes, wherefuho: Probable or Confirmed Case? o a =, ray 4 Did you have any of the following signs and symptoms for the Ove. Oo nm ast 14 days? Fever, Cough, Colds, Sore Throat, 1M? 5 Did you undergo any COVID-19 tex TL ves whens ‘Rapid Anti Body Test, here On 3 IPR (Swab Tes) Rests : 2. Ace you living with rend, family relative within the samme household? Yes. How many? [no 2 tsthere any household members that are working ouside? [1 ves. tow many? [no 3.5 there any confirmed COVIO-S cate from ater household members’ wortptace? ||] Yes [Jno PHILIPPINE AIR FORCE 520TH AIR BASE WING [AIR FORCE GENERAL HOSPITAL Colonel Jesus Vilamor Air Base, Pasay City (COVID-19 HEALTH DECLARATION FORM. ae = rasriaaae Tae Tan iE = aera Tonner at Roane eo SRT or GUAT wanton onaar a = 1 Have you worked or vied, wanaited or wavelled to other places| |] Vex local/forelgn) where: a countries for the past 14 days? = 2. Rave you visited places of positive COVID-15? Es Tn 7. Have you been in dove contact with person whoiza Suspect, | [_] Yes, where/who: pie Probable or Confirmed Case? Yes when: 4d youhave any ofthe fllowing sign and ymptomsforthe | L_] Y** =. ast 14 days? Fever, Cough, Colds, Sore Theos, LEN? id you undergo any COVID-I9 tex Lives when: > Rope ody Test Saas! On b.RI-PCR (Swab Te 1. Ace you living with a fiend, family o relative within the same howschld? [ves How many? One 2.ts there any household members that are working outside? Lives. tow many? Lino SS ee foe Ln.1 Do youlive nan are wa reported communtiy level ranean? Oe Dn _2.At present, how many are the reported confirmed COVID-19 cases in your BRGY? 3 Mow ar do youve rom the hoch witha conimed postive cane yourara? + Dovyou have any possible dose contact rom those confimed or pratable aes? LJ Yeo or Ido hereby certify that the information provided are true and correct, hence, | assume full liability under RA 11332, otherwise known as Law on Reporting of Communicable Diseases. ‘Signature over Printed Name Date and Time FOR MEDICAL OFFICER ONLY Essentially Well Adult at the time of assessment: O ves [No eee i ma Se a Exhibit any signs and symptorns of OVID-19 for the past 14 days? O ves NO ree Fit t0 Travel (Air/Land/Sea): YES (Mino Fetowork _ [] YES (no Physician Dae and tine 4. Doyou vein an area with a reported community level transmission? Ove Ono 2.At present, how many are the reported confirmed COVID-19 casesin your BRGY? 3. How far do you lve from the household with 2 confierned postive case in your area? +4. Do you have any possible close contact from those confirmed or probable cases? ako oor Ido hereby certify that the information provided are true and correct, hence, | assume full liability under RA 11332, otherwise known as Law on Reporting of Communicable Diseases. Signature over Printed Name Date and'Time FOR MEDICAL OFFICER ONLY Essentially Well Adult at the time of assessment: (yes Ono others: [Exhibit any signs and symptoms of OVID-19 for the past 14 days? Oves (no Fitto Travel (Air/land/Sea}: — [_] YES (no Fitto Work: [_] YES (no Physician Date and Time