HEALTH DECLARATION FORM

Name of Examinee:

Home Address:

Contact Number:

School Testing Center:

Date and Time of the Exam:

Yes
No
1
Are you experiencing
a.
Sore throat
b.
Body pains

c.
Headache

d
Fever for the past few days

2
Have you worked together or stayed in
the same close environment
of a confirmed COVID-19 case?

3
Have you had any contact with anyone
with fever, cough, colds and
sore throat in the past 2 weeks?

4
Have you travelled outside of the
Philippines in the last 14 days?

5
Have you travelled to any area in
Region 10 aside from your home?

6
For Female Examinee: Are you
pregnant?

7
Do you have any comorbidities,
immunodeficiency or other health
risk?
HEALTH DECLARATION FORM
Name of Examinee:

Home Address:

Contact Number:
School Testing Center:

Date and Time of the Exam:

Yes
No
1
Are you experiencing
a.
Sore throat

b.
Body pains

c.
Headache
d
Fever for the past few days

2
Have you worked together or stayed in
the same close environment
of a confirmed COVID-19 case?

3
Have you had any contact with anyone
with fever, cough, colds and
sore throat in the past 2 weeks?

4
Have you travelled outside of the
Philippines in the last 14 days?

5
Have you travelled to any area in
Region 10 aside from your home?

6
For Female Examinee: Are you
pregnant?

7
Do you have any comorbidities,
immunodeficiency or other health
risk?
Republic of the Philippines
Department of Education
Region XII
I-UP SCHOOL OF TACURONG CITY INC.
Bonifacio St., Barangay Poblacion,
Tacurong City, Sultan Kudarat
PUPIL’S HEALTH DECLARATION FORM
Date:____________________
NAME OF PUPILS:
GENDER: AGE: TEMPERATURE:
ADDRESS:
TYPE OF VEHICLE:
VEHICLE PLATE NUMBER:
GUARDIAN:
PLACES THAT HAVE BEEN VISITED IN THE LAST 14 DAYS:
HAVE YOU BEEN SICK OF ANY OF THE FOLLOWING IN THE LAST 14 DAYS:
SICKNESS YES NO
FEVER
COUGH
SORE THROAT
DIFFICULTY IN BREATHING
DIARRHEA
OTHERS

Republic of the Philippines

Department of Education
Region XII
I-UP SCHOOL OF TACURONG CITY INC.
Bonifacio St., Barangay Poblacion,
Tacurong City, Sultan Kudarat
HEALTH DECLARATION FORM
Date:____________________
NAME OF PUPILS:
GENDER: AGE: TEMPERATURE:
ADDRESS:
TYPE OF VEHICLE:
VEHICLE PLATE NUMBER:
Guardian:
PLACES THAT HAVE BEEN VISITED IN THE LAST 14 DAYS:
HAVE YOU BEEN SICK OF ANY OF THE FOLLOWING IN THE LAST 14 DAYS:
SICKNESS YES NO
FEVER
COUGH
SORE THROAT
DIFFICULTY IN BREATHING
DIARRHEA
OTHERS