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Health Checklist Form
dssmpampanga@gmail.com
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* Required
Email
*
Your email
Untitled Title
Temperature
*
Your answer
Full Name
*
Your answer
Gender
Female
Male
Clear selection
Age
*
Your answer
Residence
*
Your answer
Contact Number
*
Your answer
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.
*
Body Pains
Headache
Fever
Cough
Sneezing/Runny or Stuffy Nose
Shortness of breath
NONE OF THE ABOVE
Other:
Required
Have you recently been in contact with anyone who has tested positive for COVID-19?
*
Yes
No
By submitting this form, you allow David's Salon SM Pampanga 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.
A copy of your responses will be emailed to the address you provided.
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