SELF-QUARANTINE MONITORING SHEET

NAME: AGE:
DATE OF BIRTH: GENDER:
ADDRESS:

DAY DAY DAY DAY DAY

DATE STARTED DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8 DAY 9
10 11 12 13 14

AM
TEMPERATURE
PM

PLEASE CHECK IF YOU DEVELOP ANY OF THE FOLLOWING:

FEVER (≥38°C and above)

CHILLS

SORE THROAT

DRY COUGH

 If you develop any symptoms, refer to Home Care Instructions for Persons under Monitoring.
 If you did not develop any symptoms after 14 days, please bring your Discharge Instructions and completely filled-up Self-
Quarantine Monitoring Sheet to your attending physician for clearance.

Patient’s Name and Signature