ALABEL NATIONAL SCIENCE HIGH SCHOOL

BRGY. MARIBULAN, ALABEL, SARANGANI PROVINCE

HEALTH DECLARATION CHECKLIST

IMPORTANT REMINDER: The information gathered on this form will be used only to determine whether you may be infected with COVID-19. The information on this form is strictly confidential.

PERSONAL DATA
Name: ____________________ Age: __ Sex: □Male □Female Civil Status: ____ Nationality: ___________________
(Last Name) (First Name) (Middle Initial)

Address: __________________Contact Number: ____________Email Address: _________

Please enumerate, if any, cities in the Philippines you have lived, worked, transited in the past 14 days:____________________________________________________________________
Please enumerate, if any, foreign countries you have lived, worked, transited in the past 14 days : ________________________________________________________________________

Date: Date: Date: Date: Date: Date: Date: Date:

Please indicate if you have any of □Fever (>37.7) □Difficulty of breathing □Sore throat □Loss of taste and smell □Diarrhea □Colds/Runny nose
the following at present or during □Cough □Body weakness □Headache □Fatigue □Body aches □Nausea/Vomiting
the past 14 days (If no symptom/s,
put NONE):
__________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________
1. In the last 14 days, have you been □Yes □No □Yes □No □Yes □Yes □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
in close contact or exposed to any
person suspected of COVID-19?
2. Were you confined in a □Yes □No □Yes □No □Yes □Yes □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
hospital/health care facility during
the past 14 days?
3. Have you been diagnosed to have □Yes □No □Yes □No □Yes □Yes □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
pneumonia in the past 14 days?
4. Did you visit any health facility, □Yes □No □Yes □No □Yes □Yes □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
hospital or clinic in the past 14 days?
5. Do you have any household □Yes □No □Yes □No □Yes □Yes □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
member/s or close contact/s who
are currently having fever, cough, or
any respiratory problems?
6. In the last 14 days, have you been □Yes □No □Yes □No □Yes □Yes □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
in contact with a COVID-19
confirmed person?
7. Have you undergone any test for □Yes □No □Yes □No □Yes □Yes □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
SARS-COV2 for the past 14 days?
Signature of Parent/Guardian

Signature of Learner
 ALABEL NATIONAL SCIENCE HIGH SCHOOL
BRGY. MARIBULAN, ALABEL, SARANGANI PROVINCE

Signature of Adviser

Note: If YES any of the following above please go home and do some self-quarantine for the meantime. Inform the teacher immediately.