INOPACAN NATIONAL HIGH SCHOOL HEALTH CHECKLIST INOPACAN NATIONAL HIGH SCHOOL HEALTH CHECKLIST

PERSONAL DATA PERSONAL DATA

DATE: DATE:
Name: RAMIREZ, JASMIN MOVE Name: RAMIREZ, JASMIN MOVE
(Last name, First Name, Middle Name) (Last name, First Name, Middle Name)

Temperature: Temperature:
Teaching Non- Parent Student Visitor Teaching Non- Parent Student Visitor
( / ) teaching ( ) ( ) ( ) ( / ) teaching ( ) ( ) ( )
( ) ( )
Address: BRGY. TINAGO, INOPACAN, LEYTE Address: BRGY. TINAGO, INOPACAN, LEYTE
Age: 45 Nationality: FILIPINO Age: 45 Nationality: FILIPINO
Sex: FEMALE Civil Status: MARRIED Sex: FEMALE Civil Status: MARRIED
Contact Number:09183666290 Contact Number:09183666290
Email Address: jasmin.ramirez001@deped.gov.ph Email Address: jasmin.ramirez001@deped.gov.ph
TRAVEL HISTORY TRAVEL HISTORY
Please list down the 3 most recent places you visited before arriving in Please list down the 3 most recent places you visited before arriving in
Inopacan NHS Inopacan NHS
Name of place Travel Mode of Transportation Name of place Travel Mode of Transportation
Visited Date Public Private Others Visited Date Public Private Others
Period Period
1. 1.
2. 2.
3. 3.
MEDICAL HISTORY: MEDICAL HISTORY:
Are you experiencing any of the following symptoms? Are you experiencing any of the following symptoms?
FEVER ( ) YES ( ) NO Have you been FEVER ( ) YES ( ) NO Have you been
COUGH ( ) YES ( ) NO exposed to any COUGH ( ) YES ( ) NO exposed to any
SHORTNESS OF ( ) YES ( ) NO Covid-19 SHORTNESS OF ( ) YES ( ) NO Covid-19
BREATH patient? BREATH patient?
( ) YES ( ) NO ( ) YES ( ) NO
SIGNATURE: SIGNATURE:

INOPACAN NATIONAL HIGH SCHOOL HEALTH CHECKLIST INOPACAN NATIONAL HIGH SCHOOL HEALTH CHECKLIST
PERSONAL DATA PERSONAL DATA
DATE: DATE:
Name: RAMIREZ, JASMIN MOVE Name: RAMIREZ, JASMIN MOVE
(Last name, First Name, Middle Name) (Last name, First Name, Middle Name)
Temperature: Temperature:
Teaching Non- Parent Student Visitor Teaching Non- Parent Student Visitor
( / ) teaching ( ) ( ) ( ) ( / ) teaching ( ) ( ) ( )
( ) ( )
Address: BRGY. TINAGO, INOPACAN, LEYTE Address: BRGY. TINAGO, INOPACAN, LEYTE
Age: 45 Nationality: FILIPINO Age: 45 Nationality: FILIPINO
Sex: FEMALE Civil Status: MARRIED Sex: FEMALE Civil Status: MARRIED
Contact Number:09183666290 Contact Number:09183666290
Email Address: jasmin.ramirez001@deped.gov.ph Email Address: jasmin.ramirez001@deped.gov.ph
TRAVEL HISTORY TRAVEL HISTORY
Please list down the 3 most recent places you visited before arriving in Please list down the 3 most recent places you visited before arriving in
Inopacan NHS Inopacan NHS
Name of place Travel Mode of Transportation Name of place Travel Mode of Transportation
Visited Date Public Private Others Visited Date Public Private Others
Period Period
1. 1.
2. 2.
3. 3.
MEDICAL HISTORY: MEDICAL HISTORY:
Are you experiencing any of the following symptoms? Are you experiencing any of the following symptoms?
FEVER ( ) YES ( ) NO Have you been FEVER ( ) YES ( ) NO Have you been
COUGH ( ) YES ( ) NO exposed to any COUGH ( ) YES ( ) NO exposed to any
SHORTNESS OF ( ) YES ( ) NO Covid-19 SHORTNESS OF ( ) YES ( ) NO Covid-19
BREATH patient? BREATH patient?
( ) YES ( ) NO ( ) YES ( ) NO
SIGNATURE: SIGNATURE: