HEALTH STATUS ASSESSMENT FORM

Date Accomplished Last Name: Sigua-Liao

04/23/2021 20:29:39 First Name: Denise Marie
Middle Name: Laowingco
Are you visiting as Date of Birth: 09/24/1986
Patient Age: 34 Sex: Female
Contact No: +639171923203 Email: denisesigua@gmail.com
Unit/Department to visit Address: 123 Speaker E. Perez corner N.S. Amoranto Street Quezon City Brgy.
Doctor's Clinic Maharlika, SMH

Screening - Symptoms Within 14 days

Symptom/s Experienced:

Do you have a household member diagnosed with COVID-19? No

Do you travel or a resident in an area reporting local transmission of COVID-19 in the past 14 days? No

Contact or exposure to someone with recent travel to an area with local transmission of COVID-19 No

Are you 60 years old and above and/or do you have any pre-existing medical condition? Yes Bronchial Asthma, Allergic Rhinitis

History of COVID-19 Infection

Have you been tested of COVID-19? What kind of COVID-19 Test did you take?
No Date Tested Result

I affirm the truthfulness and accuracy of the above stated information as required under RA 11332, "Mandatory Reporting of
Notifiable Diseases and Health Events of Public Health Concern Act". I hereby authorize Manila Doctors Hospital to collect
and process data indicated herein for the purpose of contact tracing and effecting control of the COVID-19 spread.

_____________________
Sigua-Liao , Denise Marie Laowingco
Signature printed name

DO NOT FILL OUT THIS PORTION (FOR MDH PROCESSOR ONLY) Assessment
Cleared _________________________
Send to Emergency Department Signature over printed name

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