Temperature:_______ Temperature:_________

Te
Republic of the Philippines Republic of the Philippines
Department of Education Department of Education
REGION XI REGION XI
SCHOOLS DIVISION OF DIGOS CITY SCHOOLS DIVISION OF DIGOS CITY

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Date: _____________ Contact no: _____________________ Date: _____________ Contact no: _____________________
Name: __________________________________ Age: _______ Name: __________________________________ Age: _______
Address: _________________________________ Sex: ________ Address: _________________________________ Sex: ________

Palihug ug check ( ) kung naa ka aning mga musunod: Palihug ug check ( ) kung naa ka aning mga musunod:

ubo (cough) ubo (cough)

sip-on (colds) sip-on (colds)
lisud sa pag-ginhawa (difficulty of breathing) lisud sa pag-ginhawa (difficulty of breathing)
kalintura (fever) kalintura (fever)
labad sa ulo (headache) labad sa ulo (headache)
kalibanga (diarrhea) kalibanga (diarrhea)
sakit sa tutunlan (sore throat) sakit sa tutunlan (sore throat)
pag-kawala sa panlasa (loss of taste) pag-kawala sa panlasa (loss of taste)
pag-kawala sa panimhot (loss of smell) pag-kawala sa panimhot (loss of smell)
panakit sa lawas sa walay klarong hinungdan (body malaise) panakit sa lawas sa walay klarong hinungdan (body malaise)

Biyahe: Local Lugar: _______________ Petsa: __________ Biyahe: Local Lugar: _______________ Petsa: __________
International Lugar: ____________ Petsa: _______ International Lugar: ____________ Petsa: _______
Wala Wala

Nakasinati ba ug: kalintura sa miaging semana Nakasinati ba ug: kalintura sa miaging semana
ubo sa miaging semana ubo sa miaging semana
sip-on sa miaging semana sip-on sa miaging semana
Wala Wala

_____________________________ _____________________________
Name & Signature Name & Signature

Health & Nutrition Unit Form No. ___, September 15, 2020 Health & Nutrition Unit Form No. ___, September 15, 2020

Temperature:________ Temperature:__________
Republic of the Philippines Republic of the Philippines
Department of Education Department of Education
REGION XI REGION XI
SCHOOLS DIVISION OF DIGOS CITY SCHOOLS DIVISION OF DIGOS CITY

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Date: _____________ Contact no: _____________________ Date: _____________ Contact no: _____________________
Name: __________________________________ Age: _______ Name: __________________________________ Age: _______
Address: _________________________________ Sex: ________ Address: _________________________________ Sex: ________

Palihug ug check ( ) kung naa ka aning mga musunod: Palihug ug check ( ) kung naa ka aning mga musunod:

ubo (cough) ubo (cough)

sip-on (colds) sip-on (colds)
lisud sa pag-ginhawa (difficulty of breathing) lisud sa pag-ginhawa (difficulty of breathing)
kalintura (fever) kalintura (fever)
labad sa ulo (headache) labad sa ulo (headache)
kalibanga (diarrhea) kalibanga (diarrhea)
sakit sa tutunlan (sore throat) sakit sa tutunlan (sore throat)
pag-kawala sa panlasa (loss of taste) pag-kawala sa panlasa (loss of taste)
pag-kawala sa panimhot (loss of smell) pag-kawala sa panimhot (loss of smell)
panakit sa lawas sa walay klarong hinungdan (body malaise) panakit sa lawas sa walay klarong hinungdan (body malaise)

Biyahe: Local Lugar: _______________ Petsa: __________ Biyahe: Local Lugar: _______________ Petsa: __________
International Lugar: ____________ Petsa: _______ International Lugar: ____________ Petsa: _______
Wala Wala

Nakasinati ba ug: kalintura sa miaging semana Nakasinati ba ug: kalintura sa miaging semana
ubo sa miaging semana ubo sa miaging semana
sip-on sa miaging semana sip-on sa miaging semana
 Wala Wala

_____________________________ _____________________________
Name & Signature Name & Signature

Health & Nutrition Unit Form No. ___, September 15, 2020 Health & Nutrition Unit Form No. ___, September 15, 2020