Health Checklist Form
Sign in to Google
to save your progress.
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.
Sneezing/Runny or Stuffy Nose
Shortness of breath
NONE OF THE ABOVE
Have you recently been in contact with anyone who has tested positive for COVID-19?
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.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service