Health Condition Declaration Form

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Pursuant to Republic Act 11332, you are required to provide truthful information about your health condition and possible exposure.

Dear Patients, I would like to ensure both our safety during and after your consult/procedure in my clinic. Let us make this happen by checking the appropriate box

Email *

LAST NAME *

FIRST NAME *

Date *

YYYY

Do you and/or child have fever?

Yes

Clear selection

Do you and/or child have sore throat?

Yes

Clear selection

Are you and/or child experiencing cough or colds?

Yes

Clear selection

Do you and/or child have shortness if breath or difficulty of breathing?

Yes

Clear selection

Do you and/or child experiencing headaches?

Yes

Clear selection

Do you and/or child have muscle pains?

Yes

Clear selection

Do you and/or child have diarrhea?

Yes

Clear selection

Did you and/or child consult a medical doctor for the above mentioned sign and symptoms?

Yes

Clear selection

DO you and/or child have a history of travel within 14 days? If yes, where and when? (Write in the OTHER option provided below.

Yes

Other:

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Have you and/or your child travelled to or live in local areas outside the Philippines where there are reported cases of Covid-19?

Yes

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Do you and/or your child have contact or exposure to someone who travelled in areas with local transmission?

Yes

Clear selection

Have you and/or your child been exposed to a person with a suspected/ probable/ positive case of Covid-19

Yes

Clear selection

Do you or anyone in the household have any of the above mentioned signs and symptoms or pending COVID-19 test results?

Yes

Clear selection

Submit

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