Health Symptoms Questionnaire

Date*

Date

Full Name*

First NameLast Name

Age

What is your Gender?*

MaleFemale

Company*

Mall / Dept

Temperature*

Are you experiencing / Nakakaranas ka ba ng?*

Sore Throat (Pananakit ng Lalamunan/masakit lumunok)Body Pains (Pananakit ng katawan)Headache (Pananakit ng ulo)Fever for the past few days (Lagnat sa nakalipas na ilang araw)No, I don't feel any symptoms (Walang sintomas)

Have you worked together or stayed in the same close environment of aconfirmed COVID-19 case? (May nakasama ka ba onakatrabahong tao na kumpirmadong may COVID-19 o may impeksyon ng coronavirus?)*

YesNo

Have you had any contact with anyone with fever, cough, colds or sorethroat in the past 2 weeks? (Nakipagugnayan ka basa isang taong may lagnat, ubo, sipon o pananakit ng lalamunan sa loob ngnakaraang dalawang linggo?)*

YesNo

Have you traveled outside of the Philippines in the last 14 days? Ikaw ba ay bumiyahe sa labas ng Pilipinas sa nakalipas na14 na araw?*

YesNo

If YES, please specify where? Kung “oo”, saan?

Have you ever travelled to any area in NCR aside from your home? Ikaw ba ay bumiyahe sa iba pang parte ng NCR maliban sa iyong tirahan?*

YesNo

If YES, please specify where? Kung “oo”, saan?

Consent

I hereby grant my express, unconditional, voluntary and informed consent to Shopping Center Management Corporation (SCMC), and herby authorize them to collect my personal and health information for the purpose of profiling, and to further process, share and/or store in light of health and safety requirements. I hereby knowingly and voluntarily acknowledge and confirm that I have been duly informed of my rights under the law with respect to my personal and health information provided herein. I understand that my personal information is protected under the Data Privacy Act of 2012; and, I am required under RA 11469, Bayanihan To Heal As One Act to provide truthful information. I hereby confirm that I have executed the same on my own volition and free will.

With Consent*

YesNo

HEALTH SYMPTOMS QUESTIONNAIRE