ATENEO DE DAVAO UNIVERSITY

1/F Administrative Building, McArthur Highway,

Bangkal, Davao City, Philippines
Tel no: +63 (82) 221-2411 local 6905
In consortium with Ateneo de Zamboanga University and Xavier University
U N I V E R S I T Y C L I N I C S , S H S U N I T

HEALTH DECLARATION

Name: _____________________________________________________ Age: _____ Sex: ______ Temp: ________

Home Address: ______________________________________________Barangay: ___________________________
Area of Destination/Office: ___________________ Time In: ____________ AM / PM
1. Have you travelled for the past 2 – 3 weeks (International/Domestic/Outside Davao City)? Yes [ ] No [ ]
If yes, where ________________________
when _________________________ Date of arrival in Davao City: _____________________
2. Please check if you have the following signs and symptoms for the past 14 days:
[ ] Fever [ ] Colds [ ] Sore Throat [ ] Fatigue [ ] Body Pain
[ ] Cough [ ] Diarrhea [ ] Headache [ ] Difficulty of breathing
3. Are you exposed or attending to patient with suspected and/or confirmed COVID 19? Yes [ ] No [ ]
If yes, when ________________________
4. Vaccinated against Covid-19? [ ] Fully Vaccinated [ ] Partially Vaccinated [ ] Unvaccinated
Booster shot received, Yes [ ] No [ ]
If vaccinated, what is the Brand of your Vaccine? ___________________
I hereby certify that everything stated above is true and correct.
_______________________________________ ____________________________ ____________________________
SIGNATURE ABOVE PRINTED NAME DATE CONTACT NUMBER

ATENEO DE DAVAO UNIVERSITY

1/F Administrative Building, McArthur Highway,
Bangkal, Davao City, Philippines
Tel no: +63 (82) 221-2411 local 6905
In consortium with Ateneo de Zamboanga University and Xavier University
U N I V E R S I T Y C L I N I C S , S H S U N I T

HEALTH DECLARATION

Name: _____________________________________________________ Age: _____ Sex: ______ Temp: ________

Home Address: ______________________________________________Barangay: ___________________________
Area of Destination/Office: ___________________ Time In: ____________ AM / PM
1. Have you travelled for the past 2 – 3 weeks (International/Domestic/Outside Davao City)? Yes [ ] No [ ]
If yes, where ________________________
when _________________________ Date of arrival in Davao City: _____________________
2. Please check if you have the following signs and symptoms for the past 14 days:
[ ] Fever [ ] Colds [ ] Sore Throat [ ] Fatigue [ ] Body Pain
[ ] Cough [ ] Diarrhea [ ] Headache [ ] Difficulty of breathing
3. Are you exposed or attending to patient with suspected and/or confirmed COVID 19? Yes [ ] No [ ]
If yes, when ________________________
4. Vaccinated against Covid-19? [ ] Fully Vaccinated [ ] Partially Vaccinated [ ] Unvaccinated
Booster shot received, Yes [ ] No [ ]
If vaccinated, what is the Brand of your Vaccine? ___________________
I hereby certify that everything stated above is true and correct.
_______________________________________ ____________________________ ____________________________
SIGNATURE ABOVE PRINTED NAME DATE CONTACT NUMBER