HEALTH CONDITION DECLARATION FORM

Dear Patient:

Kindly help us ensure your safety, as well as that of the medical staff in the clinic, during
and after your consult/procedure in my clinic. Kindly check the corresponding box to
your answer. We thank you for your cooperation regarding this matter.

YES NO
Do you have the following -
fever?
sore throat?
cough or colds?
shortness of breath or difficulty breathing?
headaches and low energy level?
diarrhea?
muscle pain?
new onset rashes?
Did you consult a medical doctor for the above mentioned
signs and symptoms?
Did you have history of travel within 14 days?
If YES, where ______________________________________
when ______________________________________

Did you have contact or exposure to someone who travelled

in areas with local transmission?
Have you been exposed to a person with a
suspected/probable/positive case of Covid-19?
Do you and/or anyone in your household have any of the above
mentioned signs and symptoms or pending COVID-19 test results?

I hereby certify that the information given above are true, correct and complete. I
understand that I will be held criminally liable for failure to give the right information
or intentionally providing wrong information.

Patient Name : _________________________________________

Signature over printed name

Address : __________________________________________

Contact Nos. : __________________________________________

Date : __________________________________________