Pru Life UK
COVID-19 Pre-screening Form
State / Province
Postal / Zip Code
Type a question
Do you have a fever or above normal temperature?
Have you experienced shortness of breath or had trouble breathing?
do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Have you been in contact with someone who is PUM (Person Under Monitoring) or PUI (Person Under Investigation) for COVID-19 in the last 14 days?
Have you been tested for COVID-19 and are awaiting results?
Have you traveled outside the Philippines by air or cruise ship in the past 14 days?
Have you traveled within the Philippines by air, bus, or train within the past 14 days?
Have you attended a mass gathering, a reunion of relatives/ friends, parties within a month prior to this appointment?
Do you have a weakened immune system?
Do you take steroids for any conditions? Examples of common steroids are Cortisone, Prednisone, Methylprednisone.
Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis?
Do you have diabetes?
If so, do you have to take insulin injections?
Do you have asthma or COPD?
Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy?
If yes, please explain below
Signature: by signing, you acknowledge that the answers you provided are true and accurate to the best of your knowledge
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