COVID-19 CIF (OUP)

INTRODUCTION

Mak ati Me d ic al Ce nte r e ns ure s the s afe ty o f its p atie nts , e mp lo ye e s , vis ito rs and
the c o mmunity b y id e ntifying hig h-ris k p atie nts and me d ic al s taff manag ing the m
ac c o rd ing ly.

In c o mp lianc e with RA 11332 Mand ato ry Re p o rting o f No tifi ab le Dis e as e s and

He alth Eve nts o f Pub lic He alth Co nc e rn Ac t, it is e s s e ntial that yo u p ro vid e truthful
info rmatio n ab o ut yo ur he alth c o nd itio n and p o s s ib le e xp o s ure .

Ple as e fill-o ut this fo rm at le as t 24 hour s be f or e yo ur s c he d ule d ap p o intme nt.

Validit y: This s c re e ning fo rm will b e valid f or five (5) days . Any s ymp to m whic h
may d e ve lo p o r any unp ro te c te d e xp o s ure within this c o ve rag e p e rio d will
auto matic ally invalid ate this initial s c re e ning s e s s io n.

Re minde r s :
1. NO COVID Case Investigation Form (CIF), NO swabbing and NO entry.
2. NO mas k, NO f ac e s hie ld, NO e nt r y.
3. Allo w time fo r the rmal s c re e ning .
4. O b s e rve s o c ial d is tanc ing at all time s .
5. Co me Ap p ro ximate ly 20 minut e s b e fo re yo ur p ro c e d ure .
6. O nly o ne (1) c o mp anio n is allo we d p e r p atie nt*

NOTE: Fields with asterisk (*) are the fields that are required to answer in this form Failure to answer these fields will not
proceed to the next page of the form.

DATA PRIVACY CONTENT

COVID-19 CIF (OUP)

INFORMATION REGISTRATION & GENERAL CONSENT *

TO THE PATIENT/REQUESTOR: YOU HAVE THE RIGHT TO BE INFORMED ABOUT YOUR PERSONAL DATA WHICH WILL BE ENTERED INTO OUR
SYSTEM AND THE PURPOSE(S) FOR WHICH THEY WILL BE PROCESSED. KINDLY READ ALL THE INFORMATION ON THIS FORM BEFORE
ACCOMPLISHING AND SIGNING IT. IF YOU HAVE QUESTION(S) OR CONCERN(S), PLEASE FEEL FREE TO ASK ANY OF OUR STAFF. TAWAGIN
ANG PANSIN NG EMPLEYADO NG MAKATI MEDICAL CENTER O TUMAWAG SA +632 8888 8999 KUNG HINDI NAKAKAUNAWA NG
INGLES.

I. Consent for Information Registration and Other Data Processing:

1. I certify that the information above are true and correct.

2. In the course of my treatment or availment of other healthcare services, I consent to the processing (collection, recording, retrieval, use,
retention and disposal/destruction) of my personal data, as provided under applicable laws, regulations and the Hospital’s policies and
guidelines. Such personal data are those relevant to purpose of my diagnoses, treatment, availment of healthcare services and processing of
hospital bills, claims, and quality improvement activities for enhancement of patient care.

3. I consent in making my information available to healthcare team members who are involved in the management of my care including
hospital’s service providers and partners, and to other applicable parties such as regulatory authorities, like Department of Health,
PhilHealth; my employer, my Health Maintenance Organization (HMO), and/or insurance provider for the payment of my hospital bills.

4. I am aware that the hospital is equipped with CCTV cameras to ensure safety and security of the patients, the employees and the
establishment.

5. I am aware of my rights in relation to the Personal Data that may be collected from me and my next of kin/legal representative, including
right to access, correction, and to object to the processing of the same. I may visit https://www.privacy.gov.ph/know-your-rights for more
details of my rights on data privacy.

6. I am aware that I may direct my complaints or questions, to the hospital's Patient Relations Department
through Patient.Relations@makatimed.net.ph, https://www.makatimed.net.ph or call (+632) 8888 999 local 3034. If my concerns are not
acted upon, I may consult MMC’s Data Protection Officer at dataprivacy@makatimed.net.ph. In case the hospital is unable to address my
concerns, I have the right to lodge a complaint before the National Privacy Commission at https://privacy.gov.phfor any privacy concern
regarding my personal data.

II. Consent for Procedure(s):

7. I and my immediate family (and/or legal representative) are aware that we will receive education regarding procedure/treatment to be
performed in Makati Medical Center. All my questions and concerns will be addressed to my satisfaction before a procedure/treatment will
be done.

8. I authorize Makati Medical Center and its staff to perform procedure(s) and treatment(s) necessary. If, during the procedure/treatment,
other condition(s) are discovered, and in the best judgement of my physician or surgeon, require an extension of the original contemplated
procedure or require additional procedure(s)/treatment(s) or test(s), I understand that this will be explained to me for my concurrence, unless
I am not able to express consent and the processing is critical to protect my life and health. I am also aware that the additional
procedure(s)/treatment(s) or test(s) may incur cost that will be added to my hospital bill.

9. I am aware that the practice of medicine is not an exact science and that no guarantee or warranty was made as to the result(s) that may
be derived from this procedure.

10. I am aware that Makati Medical Center is a teaching facility with medical students and/or trainees. There is a likelihood that medical
students and/or trainees may be assigned to participate in the care process. Their involvements are within the limit of their professional
competence, training, and experience, and are appropriately supervised at all times.

11. I understand that a separate informed consent is obtained when the planned care includes surgical or invasive procedure, anesthesia,
procedural sedation, use of blood and/or blood products, or other high risk treatment(s)/procedure(s) and/ or when data will be used for
research.

12. I agree that any cause of action arising from the aforementioned, patient confinement, diagnostic examination and treatment(s) is filed
exclusively in the courts of Makati City.

I acknowledge that I have read this “Information Registration and General Consent” in a language/dialect that I understand, and I can
clarify with any hospital staff any question. I can also refer to MMC’s website at https://www.makatimed.net.ph for more details on the
hospital’s Data Privacy Notice.

I acknowledge that this Information Registration & General Consent is valid for five (5) years or as deemed necessary.
I Ag re e wi th the p ro vi s i o n s o n the C o n s e n t fo r In fo rma ti o n R e g i s tra ti o n a n d O the r D a ta Pro c e s s i n g
a n d C o n s e n t fo r Pro c e d u re /s .
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Disease Reporting/Hospital Makati Medical Center

Name of Investigator

Last Name, First Name, Middle Initial

Date of Interview * 08-Nov-2020

dd-MMM-yyyy
Indicate the date today

PATIENT PROFILE

MMC Employee? * Yes

No

Name *
Evangelista Erlinda Esguerra
Last Name First Name Middle Name

Birthdate * 14-Jul-1945
dd-MMM-yyyy

Age 75

Gender * Male Female

Occupation * Pensioner

Civil Status *
Married

Nationality *
Filipino

Passport No.

PHILIPPINE RESIDENCE
COVID-19 CIF (OUP)

Permanent Address *
001
House/Lot/Bldg No.

Col. Vicente Riego de Dios St.

Street

Bucal 3-B
Barangay

Maragondon
Municipality/City

Cavite
Region/Province

Home Phone Number:

4684871237

Mobile Number * +63 9972859016

Email Address *
jamielberganos@gmail.com

Current Address * Yes

No

Is this the same with Permanent Address?

Home Phone Number * Yes

No

Same home phone number?

Mobile Number * Yes

No

Same mobile number?

Email Address * Yes

No

Same email address?

ADDRESS OUTSIDE THE PHILIPPINES

for Overseas Filipino Workers and Individuals with Residence Outside the Philippines

Do you have address outside the Yes

Philippines? *
No

Employer's Name
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Occupation

Place of Work

Address
216
House/Lot/Bldg No.

Janice St.
Street/Baranggay

Goose Creek South Carolina

Municipality/City Region/Province

United States
Country

Office Phone No.

Mobile Number

TRAVEL HISTORY

History of travel/visit/work in Yes

other countries with a known
No
COVID-19 transmission *
Unknown

14 days before the onset of your signs and symptoms

EXPOSURE HISTORY

History of Exposure to Known Yes

COVID-19 Case 14 days before the
No
onset of signs and symptoms: *
Unknown

Have you been in a place with a Yes

known COVID-19 transmission *
No

Unknown

14 days before the onset of signs and symptoms

NOTE: Fields with asterisk (*) are the fields that are required to answer in this form Failure to answer these fields will not
proceed to the submission of the form.
COVID-19 CIF (OUP)

CLINICAL INFORMATION

Disposition at Time of Report * Inpatient

Outpatient

Discharge

Died

Unknown

With Symptoms? * Yes

No

Date of Admission/Consultation * 09-Nov-2020

dd-MMM-yyyy

Is there any history of other Yes

illness? *
No

Chest X-ray done? * Yes

No

CXR Results: Pneumonia * Yes

No

Other Radiologic Findings *

N/A

Please specify. Indicate N/A if not applicable

Are you Pregnant? Yes

No

LMP

dd-MMM-yyyy
Last Menstrual Period

Assessed as High Risk Yes

No

Swabbed before Operation? * Yes

No
COVID-19 CIF (OUP)

Pre-Operative Requirement? * Yes

No

Requirement for OR procedure/Other procedure?

For procedure? Yes

No

SPECIMEN INFORMATION

Classification Suspect Probable Confirmed Case

If this is your second time of swabbing please select "Confirmed Case"

OUTCOME

Date of Discharge

dd-MMM-yyyy

Condition on Discharge Improved

Recovered

Transferred

Absconded

Died

Name of Informant

If patient is not available

Relationship

Contact Number

Mobile/Landline Number

COVID-19 Case Definition

1. Suspect Case - is a person who is presenting with any of the conditions below.

a. All SARI cases where NO other etiology fully explains the clinical presentation.
b. ILI cases with any one of the following:
i. with no other etiology that fully explains the clinical presentation AND
a history of travel to or residence in an area that reported local
transmission of COVID-19 disease during the 14 days prior to symptom onset OR
ii. with contact to a confirmed or probable case of COVID-19 in the two days prior to onset of illness of the
probable/confirmed COVID-19 case until the time the probable/confirmed COVID-19 case became negative on repeat
testing.
c. Individuals with fever or cough or shortness of breath or other respiratory signs or symptoms fulfilling any one of
the following conditions:
i. Aged 60 years and above
COVID-19 CIF (OUP)

ii. With a comorbidity

iii. Assessed as having a high-risk pregnancy
iv. Health worker

2. Probable case – a suspect case who fulfills anyone of the following listed below.

a. Suspect case whom testing for COVID-19 is inconclusive

b. Suspect who tested positive for COVID-19 but whose test was not conducted in a national or subnational
reference laboratory or officially accredited laboratory for COVID-19 confirmatory testing

3. Confirmed case – any individual, irrespective of presence or absence of clinical signs and symptoms, who was
laboratory confirmed for COVID-19 in a test conducted at the national reference laboratory, a subnational reference
laboratory, and/or DOH-certified laboratory testing facility.