HEALTH DECLARATION FORM HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Name: _____________________________________ Name: _____________________________________ Name: _____________________________________

Date: ______________________________________ Date: ______________________________________ Date: ______________________________________
Purpose: ___________________________________ Purpose: ___________________________________ Purpose: ___________________________________
FOR THE PAST 2 WEEKS: FOR THE PAST 2 WEEKS: FOR THE PAST 2 WEEKS:
Places Visited : ______________________________ Places Visited : ______________________________ Places Visited : ______________________________
__________________________________________ __________________________________________ __________________________________________
YES NO YES NO YES NO
Attended Gatherings: ____ ____ Attended Gatherings: ____ ____ Attended Gatherings: ____ ____
Experience signs and symptoms Experience signs and symptoms Experience signs and symptoms
Fever ____ ____ Fever ____ ____ Fever ____ ____
Colds ____ ____ Colds ____ ____ Colds ____ ____
Sore Throat ____ ____ Sore Throat ____ ____ Sore Throat ____ ____
Difficulty of Breathing ____ ____ Difficulty of Breathing ____ ____ Difficulty of Breathing ____ ____
Fatigue ____ ____ Fatigue ____ ____ Fatigue ____ ____
Diarrhea ____ ____ Diarrhea ____ ____ Diarrhea ____ ____
Temperature __________ Temperature __________ Temperature __________

I declare that the information I gave are accurate I declare that the information I gave are accurate
and that I am liable to the laws of the land if and that I am liable to the laws of the land if
I declare that the information I gave are accurate
information given are false. information given are false.
and that I am liable to the laws of the land if
information given are false.

_____________________________ _____________________________
_____________________________ Name and Signature Name and Signature
Name and Signature