Health Checklist Form
David's Salon Madison Branch
Email *
Full Name *
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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 crowded place? (e.g neighbors, family members,relative,etc.) *
Does your area of residence declared a locked down due to positive case/s? *
Have you recently been in contact with anyone who has tested positive for COVID-19? *
By submitting this form, you allow David's Salon Madison 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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