FB Health Declaration Form – HO and Projects

1. Employee Name ___________________________

2. Work Assignment _____________________________
2. Age
60 and above
Below 60
3. Do you have any of the following medical conditions ?
Hypertension / Chronic Heart Disease
Diabetes
Respiratory illnesses / Chronic Lung Disease (Asthma, Bronchitis, Emphysema)
Immunocompromised state (Cancer, Blood deficiencies,HIV/AIDS,Steroids or Chemotherapy)
Chronic Liver, Spleen , Kidney and Neurologic Diseases
High Risk Pregnancy
Morbid Obesity (BMI>40)
None
4. Current Address (pls. include specific Baranggay, Municipality, Province) _____________________________________
5. Kindly check if your area which you are presently residing has this type of quarantine restriction or none
Localized / Granular Lockdown
Enhanced
Modified Enhanced
General
Modified General
None
6. Please check any symptoms you have in the past 14 days or none
Fever
Cough
Colds
Sore Throat
Headache
Body Weakness / Fatigue
Body Malaise / Pain
Recent Loss of smell or taste
Diarrhea / Nausea / Vomiting / Loss of appetite
Difficulty of breathing / Altered Mental Status
None
7. Please check for any exposure you had during the Quarantine period in the past 14 days:
You have travelled from an area locally or abroad identified as COVID-19 hotspots by health authorities
You were identified as a Close Contact, Suspect, Probable or COVID-19 Confirmed in your Baranggay or Municipality.
You were living with or providing direct care for a COVID-19 patient
You were living in the same household with symptoms of COVID-19 within a 14-day period stated at No. 6
None
8. Are there members in the household who are: aged 60 and above, have other illnesses such as uncontrolled Hypertension,
Diabetes, Respiratory illnesses (Asthma, Bronchitis, Emphysema), High risk pregnancy
Yes
No
9. COVID-19 Vaccination Status
Fully Vaccinated, date of 1st dose _______ vaccine brand _______ / date of 2nd dose_______ vaccine brand ________ /
Booster: date of last booster shot _______ vaccine brand _______
Partially Vaccinated, date of the last dose ____________________________, vaccine brand ___________________
Unvaccinated but willing to get vaccinated, planned schedule ___________________
Unvaccinated and unwilling to be vaccinated
10. Declaration
I declare that the information above is true, correct, and complete. As warranted, I will follow instructions directed by our company
and authorized health care professionals. I understand that failure to answer any of the questions nor follow their instructions may
have serious consequences.

Print Name and Signature / Date signed: