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Section 1 of 2
HEALTH DECLARATION FORM - CLMD
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any question or any falsified response may have serious consequences. I understand that my personal information is protected by RA 10173 or the Data Privacy Act of 2012.
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MAGDALENO C. DUHILAG, JR.
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Complete Current Address (Kasalukuyang tirahan)
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Mobile/Phone Number (Numero ng telepono)
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Section 2 of 2
Choose “Yes” or “No” to each statement/question. (Pumili sa "Oo" o "Hindi" sa bawat pahayag/tanong.)
A. Are you experiencing or did you have any of the following in the last 7 days? (Ikaw ba ay may nararanasan o nakaranas ng mga sumusunod na sintomas sa nakaraang 7 na araw?)
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Yes (Oo)
No (Hindi)
Fever (lagnat)
Cough and/or Colds (Ubo at/o Sipon)
Body Pain (Pananakit ng katawan)
Sore Throat (Pananakit o pamamaga ng lalamunan)
Fatigue/Tiredness (pagkapagod)
Headache (Pananakit ng ulo)
Diarrhea (Pagtatae)
Loss of taste or smell (Nawalan ng panlasa o pang-amoy)
Difficulty of breathing (Pagkahapo o hirap sa pag hinga)
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Fever (lagnat)
2.
Cough and/or Colds (Ubo at/o Sipon)
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Body Pain (Pananakit ng katawan)
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Sore Throat (Pananakit o pamamaga ng lalamunan)
5.
Fatigue/Tiredness (pagkapagod)
6.
Headache (Pananakit ng ulo)
7.
Diarrhea (Pagtatae)
8.
Loss of taste or smell (Nawalan ng panlasa o pang-amoy)
9.
Difficulty of breathing (Pagkahapo o hirap sa pag hinga)
10.
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No (Hindi)
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B. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1 meter and for more than 15 minutes for the past 7 days? (May nkasalamuha ka ba na maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong distansya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 7 araw?)
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Yes (Oo)
No (Hindi)
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C. Have you provided direct care for a patient with probable or confirmed COVID-19 case without using proper "Personal Protective Equipment (PPE)" for the past 14 days? (Nag-alaga ka ba ng maaring o kumpirmadong pasyente na may COVID-19 ng hindi nakasuot ng tamang  "Personal Protective Equipment (PPE)" sa nakalipas na 14 araw?)
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D. Have you traveled outside Region 12 in the last 7 days? (Ikaw ba ay nagbiyahe sa labas ng Rehiyo Dose sa nakalipas na 7 na araw)
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No (Hindi)
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E. Have you traveled outside the current city/municipality where you reside? (Ikaw ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo) If yes, specify which city/municipality you went to (Sabihin kung saan)
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If yes, specify which city/municipality you went to (Sabihin kung saan)
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MAGDALENO C. DUHILAG, JR.
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Complete Current Address (Kasalukuyang tirahan)
No responses yet for this question.
Mobile/Phone Number (Numero ng telepono)
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No responses yet for this question.
A. Are you experiencing or did you have any of the following in the last 7 days? (Ikaw ba ay may nararanasan o nakaranas ng mga sumusunod na sintomas sa nakaraang 7 na araw?)
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No responses yet for this question.
B. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1 meter and for more than 15 minutes for the past 7 days? (May nkasalamuha ka ba na maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong distansya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 7 araw?)
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No responses yet for this question.
C. Have you provided direct care for a patient with probable or confirmed COVID-19 case without using proper "Personal Protective Equipment (PPE)" for the past 14 days? (Nag-alaga ka ba ng maaring o kumpirmadong pasyente na may COVID-19 ng hindi nakasuot ng tamang  "Personal Protective Equipment (PPE)" sa nakalipas na 14 araw?)
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No responses yet for this question.
D. Have you traveled outside Region 12 in the last 7 days? (Ikaw ba ay nagbiyahe sa labas ng Rehiyo Dose sa nakalipas na 7 na araw)
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No responses yet for this question.
E. Have you traveled outside the current city/municipality where you reside? (Ikaw ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo) If yes, specify which city/municipality you went to (Sabihin kung saan)
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No responses yet for this question.
If yes, specify which city/municipality you went to (Sabihin kung saan)
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No responses yet for this question.
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