Name of Facility Name of Facility

PRC License PRC License

Last Name Last Name
First Name First Name
Middle Name Middle Name
Position Position
Category Category
Category ID Category ID
PHILHEALTH ID PHILHEALTH ID
PWD ID PWD ID
Current Address Current Address
Purok Purok
House No. & Brgy. Cantoria No. 2 House No. & Brgy. Cantoria No. 2
Municipality & Province : Luna, La Union Municipality & Province : Luna, La Union
Region I Region I
Sex MALE / FEMALE Sex MALE / FEMALE
Birthdate (mm/dd/yyyy)________________________ Birthdate (mm/dd/yyyy)________________________
Civil Status Civil Status
Employment Status Employment Status
Directly in contact with COVID Patients____________ Directly in contact with COVID Patients____________
Profession Profession
Name of Employer Name of Employer
Province of Employer__________________________ Province of Employer__________________________
Address of Employer __________________________ Address of Employer __________________________
Contact Number of Employer ___________________ Contact Number of Employer ___________________
Pregnancy Status Pregnancy Status
Drug Allergy Drug Allergy
Food Allergy Food Allergy
Insect Allergy Insect Allergy
Latex Allergy Latex Allergy
Mold Allergy Mold Allergy
Pet Allergy Pet Allergy
Pollen Allergy Pollen Allergy
With Comorbidity With Comorbidity
Hypertension Hypertension
Heart Disease Heart Disease
Kidney Disease Kidney Disease
Diabetes Mellitus Diabetes Mellitus
Bronchial Asthma Bronchial Asthma
Cancer Cancer
Others Others
Patient was diagnosed with COVID19 _____________ Patient was diagnosed with COVID19 _____________
Date of First Positive Result/Specimen Collection Date of First Positive Result/Specimen Collection
(mm/dd/yyyy) (mm/dd/yyyy)
Classification of COVID19 _______________________ Classification of COVID19 _______________________
Provided Electronic Consent ____________________ Provided Electronic Consent ____________________