DAILY COVID- 19 SYMPTOMS MONITORING

Name: ___________________ Contact Number: _________________ Address: __________________________________ Monitoring Start/End Date: ____________
Instructions: Mark if you have any of the symptoms below. Please encircle Yes or No. DO NOT LEAVE ANY SPACES BLANK. This form should be submitted to XUCN
Day
Date (02/07/22)
AM PM AM PM AM PM AM PM AM PM AM PM AM PM
SpO2 %
Temperature
a. Felt Feverish / Fever Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
b Cough Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
c Shortness of Breath Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
d Chills Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
e Sore Throat Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
r Runny Nose Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
g Stuffy (Congested) Nose Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
h Loss of taste (partial or complete) Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
i Loss of smell (parial or complete) Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
j Muscle aches Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
k Fatigue Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
l Headache Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
m Abdominal pain /discomfort Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
n Nausea Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
o Vomiting Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
p Diarrhea Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Intake of Anti-pyretic or Anti-inflammatory: Specify Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
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_______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______
Number of Hand washing per day
Other Sypmtom(s)

Have you had face-to-face contact with a probable or confirmed COVID-

19 case within 1 meter and for more than 15 minutes for the past 14 days?
(May nakasalamuha k aba na probable o kumpirmadong pasyente na may
COVID-19 mula sa isang metrong distansya or mas malapit pa at tumagal
ng mahigit 15 minuto sa nakalipas na 14 araw?)

Have you had any contact with anyone with fever, cough, colds, and sore
throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat,
ubo, sipon, o sakit ng lalamuna sa nakalipas na dalawang (2) lingo?)

Have you travelled outside of the philppines in the last 14 days? (Ikaw ba
ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)

Have you had any contact with OFWs or Locally Stranded Individuals
(LSI) in the past 2 weeks? (Mayroon ka bang nakasam na OFW or LSI sa
loob ng dalawang (2) lingo?)
Have you travelled outside in the current city/municipality where you
reside? (Ikaw ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo? If
yes, specify which city/municipality you went to (Sabihin kung saan):
______________________

Clinical Instructor Initials:

Clinical Instructor: ____________________________________________________