COVID - 19 Patient Screening Questionnaire
Pursuant to Republic Act 11332, you are required to provide truthful information about your health condition and possible exposure.

To help us provide care to our patients in the midst of the COVID-19 pandemic, we are asking all patients to provide the following information prior to making an office appointment. It is essential that this information is accurate and complete. We respect your privacy and this information will be protected.Thank you for your cooperation- Asian Hair Restoration Center and Arambulo Dermatology Center.

In compliance with the Data Privacy Act of 2012, Asian Hair Restoration Center and Arambulo Dermatology Center ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.
Name *
Date Today *
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Date of birth *
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Age *
Sex *
Email *
Contact Number *
PART I. Signs and Symptoms
Have you experienced any of the following in the past 14 days? ( Please check all that applies)
PART II. TRAVEL AND EXPOSURE HISTORY
Do you have close contact (live in the same household, work in the same office, providedirect patient care, or travel together) with someone who is a probable or confirmed COVID case? *
If yes, close contact/s
Have you or any member of your household or close contacts travelled within or outside the country in the past two (2) weeks? *
If yes, place and date of travel
PART III. Agreement
By signing this form with my initials, I confirm that: I have been informed that Asian Hair Restoration Center and Arambulo Dermatology Center is undertaking these measures to ensure that the well-being and protection of everyone, myself included, is prioritized. The information I have provided are TRUE and CORRECT and I am aware that any untruthful statements I make may have serious consequences on public health and safety for which I may be held liable under the law. (Sign your Initials below) *
Are all of the above statements are true, accurate and complete? *
Required
Other Comments:
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