Republic of the Philippines

NATIONAL POLICE COMMISSION

PHILIPPINE NATIONAL POLICE
REGIONAL MEDICAL AND DENTAL UNIT 4A
Camp Vicente Lim Mayapa, Calamba City, Laguna
Email Address: rhs4a@ymail.com/ CP No. 0925-8866836

SELF ASSESSMENT CHECKLIST

Rank/Name: Date
Age/Sex: Contact No.
Unit: Purpose:
Home Address:
A. TRAVEL HISTORY within 14 days
B. HISTORY OF EXPOSURE within the last 14 days

 Have you undergone COVID-19 testing? (___)YES (___)NO

a) Rapid Test (___)YES (___)NO
If YES, when and where? _____________________
 Have you been in close contact with confirmed cases of COVID 19?
(___)YES (___)NO
 Have you been in close contact who works in a healthcare facility/hospital?
(___)YES (___)NO
 Have you been in close contact with anyone who had travel history in places with
confirmed cases of COVID 19? (___)YES (___)NO
C. PRESENCE OF THE FOLLOWING with the last 14 days:

YES NO MANIFESTATION YES NO MANIFESTATION

Fever Cough
Headache Difficulty of breathing
Nasal Congestion Shortness of Breath
Runny Nose Diarrhea
Cold Muscle spasm
Loss of Sense of Smell Change in sleeping Pattern
Loss of Appetite Others (Specify)
Sore Throat
If YES, Indicate the data, duration and
describe in details including the treatment
done etc.

I hereby certify that the information I have given herein is true, correct and complete. I
understand that failure to answer any question or falsified response may have serious
consequences. (Article 171, 17 of the Revised Penal Code of the Philippine and RA 11332).

I further attest to the truthfulness of the foregoing certification and submit to the legal and
administrative charges for Dishonesty pursuant to Rule 21, Sec 1 (14) of the NAPOLCOM MC
NO. 2016-002, If ever the data above are wanting in truth and substance.

__________________________ __________________________
Signature over Printed Name Signature over Printed Name
(Patient) (Medical Officer)