DAILY HEALTH STATUS REPORT

NAME:______________________________________________________

ADDRESS:____________________________________________________

OFFICE:______________________________________________________

I hereby declare that all the entries herein are true and correct.

1. In the past 14 days, have you or any member of your household travelled to any areas with
known case/s of COVID19? YES:________ NO_________

2. In the past 14 days, have you or any member of your household has had any contact with any
COVID19 patient? YES:________ NO_________

3. In the past 14 days, have you or any member of your household have any history of exposure to
any COVID19 biological material (e.g. saliva) YES:________ NO_________

4. Have you had any history of fever for the last 14 days: YES:________ NO_________

5. Have you had symptoms in the last 14 days?

Cough…………………………………….. YES:________ NO_________
Nausea…………………………………… YES:________ NO_________
Diarrhea………………………………… YES:________ NO_________
Loss of taste…………………………… YES:________ NO_________
Difficulty of breathing……………. YES:________ NO_________
Bodyache………………………………. YES:________ NO_________
Loss of smell………………………….. YES:________ NO_________

6. My body temperature is___________

Monitored by:
______________________________________
________________/Ralph Gerald L. Ravelo,RN
Date:_________________Time:____________

*please attach your Certificate of Non PUM/PUI