Republic of the Philippines

DEPARTMENT OF HEALTH TREATMENT AND REHABILITATION CENTER - ILOILO

Brgy. Rumbang, Pototan, Iloilo
Tel. No. (033) 529-8955 | e-mail: dohtrcwv@gmail.com

PRE-ADMISSION SCREENING FORM

PATIENT: LAST NAME FIRST NAME MIDDLE NAME AGE SEX REFERRED BY

Has the patient experienced any of the following symptoms during the past 14 days up to the present?
YES NO SIGNS/SYMPTOMS DATE OF ONSET YES NO SIGNS/SYMPTOMS DATE OF ONSET
FEVER / FEVERISH LOSS OF APPETITE
COLDS / RUNNY NOSE MUSCLE ACHES/PAIN
COUGH WEAKNESS/TIREDNESS
LOSS OF SMELL OR TASTE NAUSEA OR VOMITING
HEADACHE DIFFICULTY BREATHING OR
SORE THROAT SHORTNESS OF BREATH
DIARRHEA OTHERS, Specify

Has the patient been in close or direct contact with a suspected/probable/confirmed COVID-19 case?  YES  NO
Has the patient been in close contact with someone with COVID-19 or influenza-like symptoms?  YES  NO
Is there a cluster of influenza-like cases or respiratory illnesses in the patient’s current place of
residence or confinement?  YES  NO
HEALTH STATUS: BP: _______ PR: _______ RR: _______ TEMP: _______ Weight: _______ Height: _______
PRE-EXISTING MEDICAL CONDITIONS: YES NO HISTORY OF HOSPITALIZATION:
Chronic Lung Disease (Asthma, Emphysema, COPD, etc.)
Respiratory Disease (PTB, Pneumonia, etc.)
Diabetes Mellitus PRE-EXISTING SURGICAL CONDITIONS:
Cardiovascular Disease / Hypertension
Chronic Renal Disease
Chronic Liver Disease HISTORY OF OPERATION:
PLHIV (Person Living with HIV or AIDS)
Immunocompromised (Chronic Steroid Use, Cancer, etc.)
Neurologic / Neurodevelopmental Disability (Seizures, etc.) HISTORY OF CONSULT/TREATMENT FOR
OTHERS, Specify PSYCHIATRIC SYMPTOMS/ILLNESS:

FOOD/DRUG ALLERGIES:
CURRENT MEDICATIONS (Include Vitamins and Supplements):

FAMILY HISTORY: Asthma Cancer PTB

Diabetes Mellitus Hypertension OTHERS, Specify
I have understood the importance of the questions being asked with regards to my case. I attest that the information given are true
and to the best of my knowledge. Naintindihan ko ang importansya sang mga palamangkutanon sang medical staff nahanungod sa
akon sakit. Gina pamatud-an ko nga ang tanan nga ini matuod kag eksakto santo sa akon nahibalu-an.
I understand the moral and legal implications in disclosing false facts, and withholding information from DOH-TRC Iloilo staff. I am well
aware of the possible negative consequences of such act to the medical staff, nonmedical personnel, other patients and the rest of the
community. Nahibaluan ko ang mga legal kag moral nga implikasyon sa paghatag sang sala nga impormasyon. Kon indi ako magsugid
sang matuod, makahatag ini perwisyo sa mga doctor, nurses, iban nga empleyado sang DOH-TRC Iloilo, iban nga pasyente, kag bilog
nga miyembro sang komunidad.

INTERVIEWEE: ______________________________ INTERVIEWED BY: ____________________________________

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

DOH-TRC Iloilo Physician: _________________________ REMARKS: ______________________________________

SIGNATURE OVER PRINTED NAME
FORM-TRCNSO-031 V00 05JAN2021