Republic of the Philippines Republic of the Philippines Republic of the Philippines

Department of Education Department of Education Department of Education

Region III – Central Luzon
Schools Division of Tarlac Province
PURA CENTRAL HIGH SCHOOL
(formerly ESTIPONA HIGH SCHOOL-ANNEX)
School ID: 307003
Region III – Central Luzon
Schools Division of Tarlac Province
PURA CENTRAL HIGH SCHOOL
(formerly ESTIPONA HIGH SCHOOL-ANNEX)
School ID: 307003
Region III – Central Luzon
Schools Division of Tarlac Province
PURA CENTRAL HIGH SCHOOL
(formerly ESTIPONA HIGH SCHOOL-ANNEX)
School ID: 307003

HEALTH DECLARATION FORM HEALTH DECLARATION FORM HEALTH DECLARATION FORM

____________________ ____________________ ____________________

Petsa Petsa Petsa

Name/ Pangalan: ________________________________ Name/ Pangalan: ________________________________ Name/ Pangalan: ________________________________

Grade Level/ Baitang: _____________________________ Grade Level/ Baitang: _____________________________ Grade Level/ Baitang: _____________________________

Age/ Edad: _____________________________________ Age/ Edad: _____________________________________ Age/ Edad: _____________________________________

Temperarture/ Temperatura: ______________________ Temperarture/ Temperatura: ______________________ Temperarture/ Temperatura: ______________________

Contact Number: ________________________________ Contact Number: ________________________________ Contact Number: ________________________________

Nagkaroon ka ba ng mga sumusunod na sakit sa nakalipas Nagkaroon ka ba ng mga sumusunod na sakit sa nakalipas Nagkaroon ka ba ng mga sumusunod na sakit sa nakalipas
na pitong (7) araw? na pitong (7) araw? na pitong (7) araw?

(Markahan ng tsek (√) (Markahan ng tsek (√) (Markahan ng tsek (√)

Sakit Oo Hindi Sakit Oo Hindi Sakit Oo Hindi

Lagnat Lagnat Lagnat
Ubo Ubo Ubo
Sipon Sipon Sipon
Pagtatae Pagtatae Pagtatae
Pananakit ng lalamunan Pananakit ng lalamunan Pananakit ng lalamunan
Hirap sa paghinga Hirap sa paghinga Hirap sa paghinga
Walang panlasa at pang- Walang panlasa at pang- Walang panlasa at pang-
amoy amoy amoy

Ang lahat ng impormasyong aking ibinigay ay kumpleto at Ang lahat ng impormasyong aking ibinigay ay kumpleto at Ang lahat ng impormasyong aking ibinigay ay kumpleto at
totoo. totoo. totoo.

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Pangalan at Lagda Pangalan at Lagda Pangalan at Lagda