Health Declaration Form Health Declaration Form Health Declaration Form

The information you provide here maybe used by the public The information you provide here maybe used by the public health The information you provide here maybe used by the public health
health authorities, in accordance with the World Health authorities, in accordance with the World Health Organization, in authorities, in accordance with the World Health Organization, in
Organization, in the context of the public health response against the context of the public health response against COVID-19. The the context of the public health response against COVID-19. The
COVID-19. The form must be completed for every clients. form must be completed for every clients. form must be completed for every clients.

Full name: Full name: Full name:

Body temperature: Body temperature: Body temperature:
Contact number: Contact number: Contact number:
Purpose of visit: Purpose of visit: Purpose of visit:
Address: Address: Address:

Survey Questions YES NO Survey Questions YES NO Survey Questions YES NO

1. Do you currently have symptoms of, or have you 1. Do you currently have symptoms of, or have you been 1. Do you currently have symptoms of, or have you
been diagnosed with, pneumonia or coronavirus diagnosed with, pneumonia or coronavirus disease? been diagnosed with, pneumonia or coronavirus
disease? (COVID-19) (COVID-19) disease? (COVID-19)

2. In the past 14 days, have you been in contact with 2. In the past 14 days, have you been in contact with 2. In the past 14 days, have you been in contact with
someone who is or could be infected with coronavirus? someone who is or could be infected with coronavirus? someone who is or could be infected with coronavirus?
3. In the past 14 days, have you had any of the 3. In the past 14 days, have you had any of the following 3. In the past 14 days, have you had any of the
following symptoms? symptoms? following symptoms?
3.1. Fever 3.1. Fever 3.1. Fever
3.2. Cough 3.2. Cough 3.2. Cough
3.3. Sore throat 3.3. Sore throat 3.3. Sore throat
3.4. Runny nose 3.4. Runny nose 3.4. Runny nose
3.5. Shortness of breath 3.5. Shortness of breath 3.5. Shortness of breath
If you answered "yes" to any of the questions, pls inform the provincial If you answered "yes" to any of the questions, pls inform the provincial If you answered "yes" to any of the questions, pls inform the provincial
health personnel for proper monitoring. health personnel for proper monitoring. health personnel for proper monitoring.

Completed truthfully on: ________________________ time: _________ Completed truthfully on: ________________________ time: _________ Completed truthfully on: ________________________ time: _________

Signature Signature Signature