PAUNAWA: Mahigpit na ipinapatupad ng Kagawaran ng Edukasyon-Marinduque Division, Marinduque National High PAUNAWA: Mahigpit na ipinapatupad ng Kagawaran ng Edukasyon-Marinduque Division,

ukasyon-Marinduque Division, Marinduque National High

School ang "NO FACE MASK, NO ENTRY" bilang polisiya. Laging isuot ang inyong face mask habang kayo ay nasa loob School ang "NO FACE MASK, NO ENTRY" bilang polisiya. Laging isuot ang inyong face mask habang kayo ay nasa loob
ng opisina o paaralan. Gamitin ang sariling pansulat. ng opisina o paaralan. Gamitin ang sariling pansulat.

DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION

MARINDUQUE NATIONAL HIGH SCHOOL MARINDUQUE NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Date of Visit (Petsa ng pagbisita): _________________ Time (Oras): ________ Temperature: AM ______ PM_______ Date of Visit (Petsa ng pagbisita): __________________ Time (Oras): _______ Temperature: AM ______ PM_______

RESPONDENT INFORMATION RESPONDENT INFORMATION

Last Name (Apelyido): Last Name (Apelyido):
First Name (Unang Pangalan): First Name (Unang Pangalan):
Middle Name (Gitnang Pangalan): Middle Name (Gitnang Pangalan):
Age (Edad): Sex (Kasarian): Male Female Nationality (Nasyonalidad):_______________Age (Edad): Sex (Kasarian): Male Female Nationality (Nasyonalidad):_______________
Occupation (Trabaho):____________________________________________________________________________ Occupation (Trabaho):____________________________________________________________________________
Email Address: _________________________________ Telephone/Mobile Number: _______________________________ Email Address: __________________________________ Telephone/Mobile Number: _______________________________
Current Address (Kasalukuyang Tirahan): Barangay: ______________________________ City/Municipality: _____________________ Current Address (Kasalukuyang Tirahan): Barangay: ______________________________ City/Municipality: _____________________
Province: _______________________________________________ Region : ___________________________________ Province: ________________________________________________Region : ___________________________________
HEALTH PROFILE HEALTH PROFILE
Comorbidity Diabetes Hypertension Chronic Lung Disease Comorbidity Diabetes Hypertension Chronic Lung Disease
(Kasalukuyang Karamdaman): Heart Disease HIV/Other Immune Deficiency Chronic Liver Disease (Kasalukuyang Karamdaman): Heart Disease HIV/Other Immune Deficiency Chronic Liver Disease
Obesity Chronic Kidney Disease Cancer Obesity Chronic Kidney Disease Cancer
Asthma (requiring medication Asthma (requiring medication
Current Medication (Mga gamot na iniinom):_______________________________________________________________________________ Current Medication (Mga gamot na iniinom):___________________________________________________________________________
____________________________________________________________________________________________________ ____________________________________________________________________________________________________
Please check if you have any of the following symptoms (Pakilagyan ng tsek kung nakakaranas ng mga sumusunod na Please check if you have any of the following symptoms (Pakilagyan ng tsek kung nakakaranas ng mga sumusunod na
sintomas): sintomas):
Fever (Lagnat) Temp: ______________ Headache (sakit ng ulo) Fever (Lagnat) Temp: ______________ Headache (sakit ng ulo)
Cough (Ubo) Sore throat (Masakit na lalamunan) Cough (Ubo) Sore throat (Masakit na lalamunan)
Colds (sipon) Body weakness (Panghihina ng katawan) Colds (sipon) Body weakness (Panghihina ng katawan)
Diarrhea (Pagtatae) Difficulty of Breathing (hirap sa paghinga) Diarrhea (Pagtatae) Difficulty of Breathing (hirap sa paghinga)
Oghers, specify: _______________________________________________________________________ Oghers, specify: _______________________________________________________________________
GENERAL EXPOSURE INFORMATION GENERAL EXPOSURE INFORMATION
Did you travel within the last 30 days?(Ikaw ba ay may pinuntahang lugar nitong nakaraan na 30 na araw? Did you travel within the last 30 days?(Ikaw ba ay may pinuntahang lugar nitong nakaraan na 30 na araw?
INTERNATIONAL TRAVEL: Yes If Yes, where (saan):_________________________________ INTERNATIONAL TRAVEL: Yes If Yes, where (saan):________________________________
No Date: _______________________________ (MM/DD/YYYY) No Date: _______________________________ (MM/DD/YYYY)
DOMESTIC TRAVEL: Yes If Yes, where (saan): ________________________________ DOMESTIC TRAVEL: Yes If Yes, where (saan): ________________________________
No Date: ________________________________ (MM/DD/YYYY) No Date: ________________________________ (MM/DD/YYYY)
Mode of transportation: Plane Sea Vessel Bus Personal Vehicle Mode of transportation: Plane Sea Vessel Bus Personal Vehicle
Did you get sick for the last 14 days? (Ikaw ba ay nagkasakit nitong nakaraan na 14 na araw?) Yes No Did you get sick for the last 14 days? (Ikaw ba ay nagkasakit nitong nakaraan na 14 na araw?) Yes No
Did you visit a hospital, public/private clinic, within the last 14 days? Did you visit a hospital, public/private clinic, within the last 14 days?
(Ikaw ba ay bumisita sa ospital o pampublikong/pribadong clinic nitong nakaraan na 14 na araw? Yes No (Ikaw ba ay bumisita sa ospital o pampublikong/pribadong clinic nitong nakaraan na 14 na araw? Yes No
If, Yes where (saang ospital or clinic bumisita): _______________________________________________________________________________
If, Yes where (saang ospital or clinic bumisita): _________________________________________________________________________
Date (Petsa ng pagbisita sa ospital/cllinic): ____________________________________________________ (MM/DD/YYYY) Date (Petsa ng pagbisita sa ospital/cllinic): ____________________________________________________ (MM/DD/YYYY)
In the last 14 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19? (Sa huling 14 In the last 14 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19? (Sa huling 14
na araw, nagkaroon ka ba ng malapit na pakikipag-ugnayan o pakikisalamuha sa taong pinaghihinalaan o kumpirmadong may COVID- na araw, nagkaroon ka ba ng malapit na pakikipag-ugnayan o pakikisalamuha sa taong pinaghihinalaan o kumpirmadong may COVID-
19?) 19?)
If Yes, when is the last contact: __________________________________ (MM/DD/YYYY) If Yes, when is the last contact: __________________________________ (MM/DD/YYYY)