REPUBLIC OF THE PHILIPPINES

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES TEMPERATURE:

OFFICE OF THE VICE PRESIDENT FOR ADmINISTRATION
Date and time :
MEDICAL SERVICES DEPARTmENT

I hereby authorize Polytechnic University of the Philippines to collect and process the data indicated herein for the
purpose of mitigating COVID-19 (Corona Virus 2019). I understand that my personal information is protected by RA
10173, Data Privacy Act of 2012, and that I am required by RA 11469 , Bayanihan to Heal as One Act, to provide
truthful information.

SIGNATURE
Visual Triage Checklist for COVID-19

NAME:
PangalanLast NameGiven NameMiddle Name

AGE:SEX: □ Male□ Female

EdadKasarian

IF FEMALE, ARE YOU POSSIBLY PREGNANT/ARE YOU PREGNANT? □ Yes□ No

HOME ADDRESS:
TirahanHouse No. / Bldg No. Street NameBarangayMunicipalityProvinceRegion

CONTACT DETAILS:

TeleponoHome Telephone Number Mobile No.

A. Clinical Signs and Symptoms

Please check the box if you have any of the following: Nakararanas ka ba ng mga sumusunod?

Lagnat - Fever(T=>37.5) Hingal - Shorthness of Breath Sipon - Runny Nose

Ubo - Cough (New or Pananakit ng lalamunan - Sore Hirap sa Paghinga-
worsening)
throat Difficulty of Breathing
Pagtatae - Diarrhea

B. Risk of Exposure to Covid-19 Yes/ Oo No/Hindi

1. Have you traveled to any places or country with confirmed

cases of COVID-19 for the last 14 days?
Ikaw ba ay pumunta o nagbyahe sa mga lugar kung
saan may kumpirmadong kaso ng COVID-19 nitong nakaraang
dalawang linggo o 14 na araw?

2. Have you come into close contact with someone who is

a CONFIRMED or PROBABLE case of COVID-19 for the past
14 days?
Ikaw ba ay ay may nakasama na may ubo, lagnat, sipon o sakit ng lalamunan
o kumpirmadong may sakit na COVID-19 sa nakalipas na dalawang linggo?

3. Do you have any pre-existing Illness?

Ikaw ba ay may iba pang kasalukuyan na karamdaman tulad ng altapresyon,
dyabetis, sakit sa puso at iba pa?
If yes please specify?
Kung “Oo/Yes” Ano ang mga ito?

ASSESSED BY:

Nurse Doctor

PUP A. Mabini Campus, Anonas Street, Sta. Mesa, Manila 1016

Direct Line: 335-1745|Trunk Line: 335-1787 or 335-1777 local 385 (Medical Director’s Office, 312 (Clinic)
Website: www.pup.edu.ph| Email: medical@pup.edu.ph

THE COUNTRY’S 1ST POLYTECHNICU