COVID-19 HEALTH DECLARATION FORM

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Pantai Hospital Sungai Petani

Full Name: (As per NRIC) *

IC/Passport Number: *

Nationality: *

Malaysian

Other:

Full Address: *

Contact number (Home):

Contact number (Mobile): *

Gender: *

Male

Female

Do you have any of the following? *

Fever

Cough or shortness of breath

Flu, headache and/or body ache/Sore Throat

Loss of smell

Conjuctivitis

Not in Above

Required

Have you traveled to or resided in foreign country within 14 days before onset of illness? *

Yes

Have you been in closed contact in 14days before illness onset with a positive case of COVID-19? *

Yes

Have you attended an event associated with known COVID-19 outbreak? Eg: Tabligh gathering/Sivagangga/others gathering *

Yes

Have you worked in close proximity/shared the same classroom environment (meeting, conference etc)/travelled with a positive case of COVID-19 patient? *

Yes

Have you travelled together with a positive case of COVID-19 in any kind of conveyance? *

Yes

Have you been tested for COVID-19? *

Yes

Have you been given any health advisory (quarantine at home)? *

Yes

Reason quarantine at home under any health advisory:

Discrimination:

Patients and visitors to Pantai Hospital Sungai Petani are reminded that providing false information is an offence under the Malaysian Government Infection Disease Act. The Hospital will be obliged to report such FALSE information.

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