Scribd Logo
Upload

Welcome to Scribd!

  • Maap Health Declaration Form

    Uploaded by

    Salgie Masculino
    99 views1 page
    This document is a health declaration form for the Maritime Academy of Asia and the Pacific's infirmary. It collects contact information and health symptoms from individuals, including cough, fever, shortness of breath, and recent travel or exposure to COVID-19 positive individuals. The individual's temperature is also recorded by an MAAP representative on the day of examination.

    Original Description:

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is a health declaration form for the Maritime Academy of Asia and the Pacific's infirmary. It collects contact information and health symptoms from individuals, including cough, fever, shortness of breath, and recent travel or exposure to COVID-19 positive individuals. The individual's temperature is also recorded by an MAAP representative on the day of examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    99 views1 page

    Maap Health Declaration Form

    Uploaded by

    Salgie Masculino
    This document is a health declaration form for the Maritime Academy of Asia and the Pacific's infirmary. It collects contact information and health symptoms from individuals, including cough, fever, shortness of breath, and recent travel or exposure to COVID-19 positive individuals. The individual's temperature is also recorded by an MAAP representative on the day of examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    MARITIME ACADEMY OF ASIA AND THE PACIFIC - KAMAYA POINT

    INFIRMARY
    Associated Marine Officers’ and Seamen’s Union of the Philippines – PTGWO-ITF
    Kamaya Pt., Brgy. Alas-asin, Mariveles, Bataan

    HEALTH DECLARATION FORM

    DATE: ___________________

    NAME: _________________________________________________________

    CONTACT NO.: __________________________________________________

    ADDRESS: _______________________________________________________

    _______________________________________________________________

    BODY TEMPERATURE (to be accomplished by the MAAP


    Representative on the day of your examination): _________

    Do you have any of the following for the last 2 weeks or


    YES NO REMARKS
    today?

    Cough/ Sore throat/ Colds


    Shortness of breath
    Fever
    Headache
    Loss of smell/ taste
    Diarrhea
    Contact or exposure to COVID positive

    Recent Travel History: _____________________________________________

    Medications: ____________________________________________________

    SIGNATURE OVER PRINTED NAME

    You might also like