HEALTH ASSESSMENT FORM FOR STUDENTS HWC 044-20-02

NAME: Eugenio, Disserie Ann, A. CAMPUS: Valenzuela Campus T

AGE: 22 GENDER: Female CONTACT NOS: 09357558564 YEAR/SECTION: 1st Year BSIHM COLLEGE/STRAND: 1st Year BSIHM(
HACLO) Irregular

Answer each question by placing a check (✓) mark. YES NO

1.Have you been fully vaccinated for COVID-19 during the last 2 weeks? (2 doses, except for Janssen
vaccine which requires only 1 dose)
2.Have you experienced any of the following in the past 14 days
Sore throat
Body pain
Headache
Fever
Cough
Colds
Difficulty of breathing
Diarrhea
- Nausea/vomiting
Tiredness
Loss of taste and/or smell
Skin rash
Red eyes
Loss of movement and/or speech
Chest pain or pressure
3. Have you worked together or stayed in the same close environment with a confirmed COVID-19 case
or PUI who is under self-quarantine in your house or in your neighborhood?
4. Did you have any contact with anyone with fever, cough, colds, and sore throat in the past 14 days?

5. Have you travelled outside of the Philippines in the last 14 days?

6. Do you have any of the following conditions:

60 years old and above

Ongoing pregnancy
Hypertension
Heart disease
Diabetes mellitus
Recurrent asthma attacks
Chronic lung disease- ongoing PTB treatment
COPD
Cancer
Blood dyscrasias
Chronic liver and kidney diseases
Currently undergoing dialysis treatment
Immunocompromised status
Autoimmune disease
Other Illnesses
I fully understand that it is the policy of the Our Lady of Fatima University that no students regardless of status shall be
allowed to report for school on campus if any of the abovementioned conditions are present. A student may only report back to
school after following the 14-day quarantine protocol and submit a medical clearance/fit to school certificate from the School
Physician before reporting on campus.

For students in vulnerable group (VG): I fully understand that I must follow the prevailing guidelines prescribed by the COVID-
19
Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF).
I attest that all the information given above are true and correct and that I may be held liable for any misinformation stated
herein. I also authorize Our Lady of Fatima University to collect and process data indicated herein for the purpose of effecting
the control of COVID-19 infection and that my personal information are protected by RA.10173 (Data Privacy Act of 201°C 2)
and that I am required by RA.11469 (Bayanihan to Heal as One Act) to provide truthful information.

Student’s Signature Over Printed Name:

Date