ReeHealth Checklist Form
David's Salon SM San Lazaro
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Gender
Clear selection
Age *
Residence *
Contact Number *
Are you experiencing : body pains, headache, fever for the past few days, fatigue, cough, sneezing, diarrhea, runny or stuffy nose, shortness of breath, ? If yes, please specify. *
Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? *
Have you had any contact with anyone who has fever, cough, colds, and sore throat in the past 2 weeks? *
Have you travelled outside of the Philippines in the last 14 days? *
Have you travelled to any other city aside from your home? If yes, please specify. *
Have you been quarantined for at least 14 days? *
Have you recently been in hospital? If yes, please specify when and the reason of your hospital visit. *
Do you have any pre-existing health condition(s)? If yes, please specify. *
Have you recently been in a crown place? (e.g neighbors, family members,relative,etc.) *
Does your area of residence declared a locked down due to positive case/s? *
By submitting this form, you allow David's Salon SM City San Lazaro branch to collect and process the data indicated herein for the purpose of effecting control of the Covid-19 infection.

Your personal information is protected by RA 10173, Data Privacy Act of 2012, and required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

Have you recently been in contact with anyone who has testedpositive for COVID-19? *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms