PAMANTASAN NG LUNGSOD NG MUNTINLUPA

Form
UNIVERSITY CLINIC
University Road, Poblacion, Muntinlupa City

HEALTH DECLARATION FORM

Issue No. 0 Revision No. 0 Effectivity Date Page No. 1 of 1

NAME: _______________________________________________________________________
AGE AND GENDER: _______________________ COURSE APPLIED: ___________________
COMPLETE ADDRESS: ____________________________________________________________
_____________________________________________________________
CONTACT NUMBER: _____________________________________________________________
DATE & TIME: _________________________ TEMPERATURE: _____________________
PURPOSE OF VISIT: ______________________________________________________________
______________________________________________________________________________________
Please check the box beside the COVID-19 SYMPTOMS if you EXPERIENCE:
Sore throat Fever in the past 14 days
Body pains Difficulty of breathing
Headache LBM/Diarrhea
Cough Abdominal Pain
Colds Vomiting
Loss of Smell Loss of Taste

No COVID-19 Symptoms

Have you had:

Close contact with a confirmed COVID-19 case in the past 14 days
Close contact to anyone with symptoms in the past 14 days
Travel outside the Philippines
Travel to other regions confirmed to have elevated number of COVID-19 cases
__________________________________________________________________________________

VACCINATION STATUS:

1st Dose: _______________, ___________________, ____________________

(Date/Time) (Brand of Vaccine) (Place of Vaccination)

2nd Dose: _______________, ___________________, ____________________

(Date/Time) (Brand of Vaccine) (Place of Vaccination)

Booster Dose: _______________, ___________________, ____________________

(Date/Time) (Brand of Vaccine) (Place of Vaccination)

You agree to consent to the collection/use of your information for COVID- 19 contact tracing.

_____________________
SIGNATURE