Republika ng Pilipinas

Rehiyon III
Lalawigan ng Aurora
Bayan ng San Luis
Barangay 04 Poblacion

HEALTH ASSESSMENT FORM

Pangalan:
Apelyido Pangalan Gitnang Pangalan
Kaarawan: / / Edad: Kasarian: ( ) Lalaki ( ) Babae Numero:
Tirahan: Lahi: Filipino
Petsa ng pag-alis: Petsa ng pagdating:
Lugar ng pupuntahan:
Temperatura: May nakasalamuha bang positibo sa Covid-19:
Araw na Naramdaman Araw na Naramdaman
Lagnat: Pananakit ng Lalamunan:
Sipon: Hirap huminga:
Ubo: Kawalan ng Panglasa sa pagkain:
PARA SA LULUWAS PARA MAGPA-CHECK UP
Lugar kung saan magpapa-check up:
Mga gagawing Eksaminasyon:

Pangalan ng Nagtanong: Pangalan at Pirma ng Ininterbyu:

Petsa: Petsa:

Republika ng Pilipinas
Rehiyon III
Lalawigan ng Aurora
Bayan ng San Luis
Barangay 04 Poblacion

HEALTH ASSESSMENT FORM

Pangalan:
Apelyido Pangalan Gitnang Pangalan
Kaarawan: / / Edad: Kasarian: ( ) Lalaki ( ) Babae Numero:
Tirahan: Lahi: Filipino
Petsa ng pag-alis: Petsa ng pagdating:
Lugar ng pupuntahan:
Temperatura: May nakasalamuha bang positibo sa Covid-19:
Araw na Naramdaman Araw na Naramdaman
Lagnat: Pananakit ng Lalamunan:
Sipon: Hirap huminga:
Ubo: Kawalan ng Panglasa sa pagkain:
PARA SA LULUWAS PARA MAGPA-CHECK UP
Lugar kung saan magpapa-check up:
Mga gagawing Eksaminasyon:

Pangalan ng Nagtanong: Pangalan at Pirma ng Ininterbyu:

Petsa: Petsa:
 CONTACT TRACING FORM
NAME: DATE:
ADDRESS: CONTACT NUMBER:
BIRTHDAY: / / AGE: CIVIL STATUS: GENDER: ( ) Male ( ) Female
SYMPTOMATIC (Y/N): IF YES, WHAT SYMPTOM/S:
RAPID ANTIGEN (DATE): RT-PCR (DATE):
PHILHEALTH NUMBER:

CLOSE CONTACTS
Name: Name:
Birthday: / / Age: Birthday: / / Age:
Contact Number: Contact Number:
Symptomatic: Asymptomatic: Symptomatic: Asymptomatic:
Date of Exposure: Date of Exposure:
Generation: Generation:

Name: Name:
Birthday: / / Age: Birthday: / / Age:
Contact Number: Contact Number:
Symptomatic: Asymptomatic: Symptomatic: Asymptomatic:
Date of Exposure: Date of Exposure:
Generation: Generation:

CONTACT TRACING FORM

NAME: DATE:
ADDRESS: CONTACT NUMBER:
BIRTHDAY: / / AGE: CIVIL STATUS: GENDER: ( ) Male ( ) Female
SYMPTOMATIC (Y/N): IF YES, WHAT SYMPTOM/S:
RAPID ANTIGEN (DATE): RT-PCR (DATE):
PHILHEALTH NUMBER:

CLOSE CONTACTS
Name: Name:
Birthday: / / Age: Birthday: / / Age:
Contact Number: Contact Number:
Symptomatic: Asymptomatic: Symptomatic: Asymptomatic:
Date of Exposure: Date of Exposure:
Generation: Generation:

Name: Name:
Birthday: / / Age: Birthday: / / Age:
Contact Number: Contact Number:
Symptomatic: Asymptomatic: Symptomatic: Asymptomatic:
Date of Exposure: Date of Exposure:
Generation: Generation: