MEDICAL DECLARATION FORM

Warning: Declaration false information is a violation of Vietnamese law and may be subject to
criminal handling.

1. General information
- Full name (CAPITAL LETTERS): ……………………………………………………. Sex: 1. Male 2. Female
- Date of birth: ……./………/………… (dd/mm/yyyy)
- Passport number: ……………………………………………
- Occupation: ……………………………………………………
- Nationality: ……………………………………………………
- Phone number: ………………………………………………
2. Contact information in Vietnam
No. ……………… Street: …………………………………………………… Ward: ………………………………
District: …………………………………..… Province/City: …………………
3. Travel information
Transportation: ………………………………………………………
In the past 14 days, which province/ city / territory / country have you been to? (List in details all
the places you have been to).
……………………………………………………………………………………………………………………………………………………
…………………..………………………………………………………………………………………………………………………….……
…………………………………..…………………………………………………………………………………………………………….…
……………………………………………………….…………………………………………………………………………………..………
4. If you have any of the followings at present or during the past 14 days:

Symptom Yes No Symptom Yes No

Fever     Pneumonia    
Cough     Sore throat    
Difficulty of breathing     Fatigue    
History of exposure: During the past 14 days, did you contact to:    
Patients with suspected or confirmed COVID-19    
People from countries with COVID-19    
People who have had symptoms (fever, cough, difficulty of
breathing, pneumonia)    
Other risks of infection
…................................................................................    

- Taken samples for testing COVID-19: Yes No

Taken date: ………………………….. at: ………………………………………..
Result: Negative Positive
5. Conclusion
………………………………………………………………………………………………………………………………

DECLARANT
(Sign and write full name)