All visitors shall accomplish the visitor’s checklist

HEALTH CHECKLIST
Pursuant to Republic Act 11332, you are required to provide truthful information about
your health condition and possible exposure.

Name: ______________________________ Sex : □ Male □ Female Age : ___

Residence : __________________________________________________________________

Nature of visit (Please check one): □ Personal □ Official If official, fill-in company details below

Company Name : _______________________________________________________

Company Address : _____________________________________________________ TEMPERATURE

Dear Patients,

We would like to ensure about our safety during and after your consult/procedure in the clinic. Let us make this
happen by checking the appropriate box in this Patient Declaration Form.

For the past 14 days: YES NO Date

Do you have fever?

Do you have sore throat?

Are you experiencing cough and colds?

Do you have shortness of breath or difficulty of breathing?

Are you experiencing headaches?

Do you have muscle pain?

Do you have diarrhea?

Are you experiencing loss of smell or taste?

Did you consult a medical doctor for the above mentioned sign and symptoms?

Have you been exposed to a person with suspected/probable / positive case of COVID-19?

Do you or anyone in the household have any of the above mentioned signs and symptoms?

Do you or anyone in the household have undergone any test for COVID – RT PCR or Rapid Antibody
Test? If Yes, When? Result?
Have you undergone any laboratory or radiologic procedures from the past 14 days (CBC, CXR
etc)? If yes, when?
The information I have given is true, correct, and complete. I understand that I am required by RA 11469. Bayanihan to Heal as One Act, to
provide truthful information, and that failure to do so can be penalized in accordance with the law.

I hereby authorized MediCard Philippines Inc, to collect and process the data indicated herein for the purpose of contact tracing effecting control
of the COVID-19 transmission. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012 and that this form
will be destroyed after 30 days from the date of accomplishment, following the National Archives of the Philippines protocol.

___________________________________ ________________________

Patient’s Signature over Printed Name /DATE CP#/Email address