LOOK 2ND INTEGRATED SCHOOL

HEALTH DECLARATION FORM

LAST NAME FIRST NAME: MIDDLE NAME: DATE:
TIME:
Shade the circle in the column of your chosen answer. (Itiman ang bilog ng iyong napiling sagot.)
Sagutan ang bawat bilang ng may katapatan. YES NO
1.Are you experiencing... 1. Cough and/or colds (Ubo't sipon/ubo/sipon)
(nakakaranas ka ba ng...) 2. Sore throat (pananakit ng lalamunan/masakit lumunok)
3. Body pains (pananakit ng katawan)
4. Headache (pananakit ng ulo)
5.Fever for the past 3 days (Lagnat sa nakalipas na tatlong araw)
6.Loss of smell for the past 3 days (pagkawala ng pang-amoy sa nakalipas na tatlong
araw)
7.Loss of taste for the past 3 days (pagkawala ng panlasa sa nakalipas na tatlong araw)
8. I don't experience any of those (Ako'y walang nararanasan sa anumang nabanggit)
2.Have you stayed in the same place of a confirmed COVID-19 case for the LAST 4 DAYS without face-mask and
face-shield? (May kasama ka bang tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus sa nitong
nagdaang apat (4) na araw ng walang "face-mask" at "face-shield"?)
3.Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka
bang nakasama na may lagnat, ubo, sipon o pananakit ng lalamunan sa nakalipas na dalawang (2) linggo?)

I hereby certify that the above information is true and correct.

Signature over Printed Name

_____________________________

LOOK 2ND INTEGRATED SCHOOL

HEALTH DECLARATION FORM

LAST NAME FIRST NAME: MIDDLE NAME: DATE:
TIME:
Shade the circle in the column of your chosen answer. (Itiman ang bilog ng iyong napiling sagot.)
Sagutan ang bawat bilang ng may katapatan. YES NO
1. Are you 1. Cough and/or colds (Ubo't sipon/ubo/sipon)
experiencing... 2. Sore throat (pananakit ng lalamunan/masakit lumunok)
(nakakaranas 3. Body pains (pananakit ng katawan)
ka ba ng...)
4. Headache (pananakit ng ulo)
5.Fever for the past 3 days (Lagnat sa nakalipas na tatlong araw)
6.Loss of smell for the past 3 days (pagkawala ng pang-amoy sa nakalipas na tatlong
araw)
7.Loss of taste for the past 3 days (pagkawala ng panlasa sa nakalipas na tatlong araw)
8. I don't experience any of those (Ako'y walang nararanasan sa anumang nabanggit)
2.Have you stayed in the same place of a confirmed COVID-19 case for the LAST 4 DAYS without face-mask and
face-shield? (May kasama ka bang tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus sa nitong
nagdaang apat (4) na araw ng walang "face-mask" at "face-shield"?)
3.Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka
bang nakasama na may lagnat, ubo, sipon o pananakit ng lalamunan sa nakalipas na dalawang (2) linggo?)

I hereby certify that the above information is true and correct.

Signature over Printed Name

_____________________________
 LOOK 2ND INTEGRATED SCHOOL

HEALTH DECLARATION FORM

LAST NAME FIRST NAME: MIDDLE NAME: DATE:
TIME:
Shade the circle in the column of your chosen answer. (Itiman ang bilog ng iyong napiling sagot.)
Sagutan ang bawat bilang ng may katapatan. YES NO
1.Are you experiencing... 1. Cough and/or colds (Ubo't sipon/ubo/sipon)
(nakakaranas ka ba ng...) 2. Sore throat (pananakit ng lalamunan/masakit lumunok)
3. Body pains (pananakit ng katawan)
4. Headache (pananakit ng ulo)
5.Fever for the past 3 days (Lagnat sa nakalipas na tatlong araw)
6.Loss of smell for the past 3 days (pagkawala ng pang-amoy sa nakalipas na tatlong
araw)
7.Loss of taste for the past 3 days (pagkawala ng panlasa sa nakalipas na tatlong araw)
8. I don't experience any of those (Ako'y walang nararanasan sa anumang nabanggit)
2.Have you stayed in the same place of a confirmed COVID-19 case for the LAST 4 DAYS without face-mask and
face-shield? (May kasama ka bang tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus sa nitong
nagdaang apat (4) na araw ng walang "face-mask" at "face-shield"?)
3.Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka
bang nakasama na may lagnat, ubo, sipon o pananakit ng lalamunan sa nakalipas na dalawang (2) linggo?)

I hereby certify that the above information is true and correct.

Signature over Printed Name

_____________________________

LOOK 2ND INTEGRATED SCHOOL

HEALTH DECLARATION FORM

LAST NAME FIRST NAME: MIDDLE NAME: DATE:
TIME:
Shade the circle in the column of your chosen answer. (Itiman ang bilog ng iyong napiling sagot.)
Sagutan ang bawat bilang ng may katapatan. YES NO
2. Are you 1. Cough and/or colds (Ubo't sipon/ubo/sipon)
experiencing... 2. Sore throat (pananakit ng lalamunan/masakit lumunok)
(nakakaranas 3. Body pains (pananakit ng katawan)
ka ba ng...)
4. Headache (pananakit ng ulo)
5.Fever for the past 3 days (Lagnat sa nakalipas na tatlong araw)
6.Loss of smell for the past 3 days (pagkawala ng pang-amoy sa nakalipas na tatlong
araw)
7.Loss of taste for the past 3 days (pagkawala ng panlasa sa nakalipas na tatlong araw)
8. I don't experience any of those (Ako'y walang nararanasan sa anumang nabanggit)
2.Have you stayed in the same place of a confirmed COVID-19 case for the LAST 4 DAYS without face-mask and
face-shield? (May kasama ka bang tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus sa nitong
nagdaang apat (4) na araw ng walang "face-mask" at "face-shield"?)
3.Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka
bang nakasama na may lagnat, ubo, sipon o pananakit ng lalamunan sa nakalipas na dalawang (2) linggo?)

I hereby certify that the above information is true and correct.

Signature over Printed Name

_____________________________
 LOOK 2ND INTEGRATED SCHOOL

HEALTH DECLARATION FORM

LAST NAME FIRST NAME: MIDDLE NAME: DATE:
TIME:
Shade the circle in the column of your chosen answer. (Itiman ang bilog ng iyong napiling sagot.)
Sagutan ang bawat bilang ng may katapatan. YES NO
1.Are you experiencing... 1. Cough and/or colds (Ubo't sipon/ubo/sipon)
(nakakaranas ka ba ng...) 2. Sore throat (pananakit ng lalamunan/masakit lumunok)
3. Body pains (pananakit ng katawan)
4. Headache (pananakit ng ulo)
5.Fever for the past 3 days (Lagnat sa nakalipas na tatlong araw)
6.Loss of smell for the past 3 days (pagkawala ng pang-amoy sa nakalipas na tatlong
araw)
7.Loss of taste for the past 3 days (pagkawala ng panlasa sa nakalipas na tatlong araw)
8. I don't experience any of those (Ako'y walang nararanasan sa anumang nabanggit)
2.Have you stayed in the same place of a confirmed COVID-19 case for the LAST 4 DAYS without face-mask and
face-shield? (May kasama ka bang tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus sa nitong
nagdaang apat (4) na araw ng walang "face-mask" at "face-shield"?)
3.Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka
bang nakasama na may lagnat, ubo, sipon o pananakit ng lalamunan sa nakalipas na dalawang (2) linggo?)

I hereby certify that the above information is true and correct.

Signature over Printed Name

_____________________________

LOOK 2ND INTEGRATED SCHOOL

HEALTH DECLARATION FORM

LAST NAME FIRST NAME: MIDDLE NAME: DATE:
TIME:
Shade the circle in the column of your chosen answer. (Itiman ang bilog ng iyong napiling sagot.)
Sagutan ang bawat bilang ng may katapatan. YES NO
3. Are you 1. Cough and/or colds (Ubo't sipon/ubo/sipon)
experiencing... 2. Sore throat (pananakit ng lalamunan/masakit lumunok)
(nakakaranas 3. Body pains (pananakit ng katawan)
ka ba ng...)
4. Headache (pananakit ng ulo)
5.Fever for the past 3 days (Lagnat sa nakalipas na tatlong araw)
6.Loss of smell for the past 3 days (pagkawala ng pang-amoy sa nakalipas na tatlong
araw)
7.Loss of taste for the past 3 days (pagkawala ng panlasa sa nakalipas na tatlong araw)
8. I don't experience any of those (Ako'y walang nararanasan sa anumang nabanggit)
2.Have you stayed in the same place of a confirmed COVID-19 case for the LAST 4 DAYS without face-mask and
face-shield? (May kasama ka bang tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus sa nitong
nagdaang apat (4) na araw ng walang "face-mask" at "face-shield"?)
3.Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka
bang nakasama na may lagnat, ubo, sipon o pananakit ng lalamunan sa nakalipas na dalawang (2) linggo?)

I hereby certify that the above information is true and correct.

Signature over Printed Name

_____________________________
 LOOK 2ND INTEGRATED SCHOOL

HEALTH DECLARATION FORM

LAST NAME FIRST NAME: MIDDLE NAME: DATE:
TIME:
Shade the circle in the column of your chosen answer. (Itiman ang bilog ng iyong napiling sagot.)
Sagutan ang bawat bilang ng may katapatan. YES NO
1.Are you experiencing... 1. Cough and/or colds (Ubo't sipon/ubo/sipon)
(nakakaranas ka ba ng...) 2. Sore throat (pananakit ng lalamunan/masakit lumunok)
3. Body pains (pananakit ng katawan)
4. Headache (pananakit ng ulo)
5.Fever for the past 3 days (Lagnat sa nakalipas na tatlong araw)
6.Loss of smell for the past 3 days (pagkawala ng pang-amoy sa nakalipas na tatlong
araw)
7.Loss of taste for the past 3 days (pagkawala ng panlasa sa nakalipas na tatlong araw)
8. I don't experience any of those (Ako'y walang nararanasan sa anumang nabanggit)
2.Have you stayed in the same place of a confirmed COVID-19 case for the LAST 4 DAYS without face-mask and
face-shield? (May kasama ka bang tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus sa nitong
nagdaang apat (4) na araw ng walang "face-mask" at "face-shield"?)
3.Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka
bang nakasama na may lagnat, ubo, sipon o pananakit ng lalamunan sa nakalipas na dalawang (2) linggo?)

I hereby certify that the above information is true and correct.

Signature over Printed Name

_____________________________

LOOK 2ND INTEGRATED SCHOOL

HEALTH DECLARATION FORM

LAST NAME FIRST NAME: MIDDLE NAME: DATE:
TIME:
Shade the circle in the column of your chosen answer. (Itiman ang bilog ng iyong napiling sagot.)
Sagutan ang bawat bilang ng may katapatan. YES NO
4. Are you 1. Cough and/or colds (Ubo't sipon/ubo/sipon)
experiencing... 2. Sore throat (pananakit ng lalamunan/masakit lumunok)
(nakakaranas 3. Body pains (pananakit ng katawan)
ka ba ng...)
4. Headache (pananakit ng ulo)
5.Fever for the past 3 days (Lagnat sa nakalipas na tatlong araw)
6.Loss of smell for the past 3 days (pagkawala ng pang-amoy sa nakalipas na tatlong
araw)
7.Loss of taste for the past 3 days (pagkawala ng panlasa sa nakalipas na tatlong araw)
8. I don't experience any of those (Ako'y walang nararanasan sa anumang nabanggit)
2.Have you stayed in the same place of a confirmed COVID-19 case for the LAST 4 DAYS without face-mask and
face-shield? (May kasama ka bang tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus sa nitong
nagdaang apat (4) na araw ng walang "face-mask" at "face-shield"?)
3.Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka
bang nakasama na may lagnat, ubo, sipon o pananakit ng lalamunan sa nakalipas na dalawang (2) linggo?)

I hereby certify that the above information is true and correct.

Signature over Printed Name

_____________________________