Patient Health Declaration Form
Name
*
Mr.
Mrs.
Ms.
Prefix
First Name
Last Name
Suffix
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Have you travelled in the last 15 days?
*
Yes
No
Name of the area (s) visited. (Otherwise, write N/A)
*
Country, Province, City
Dates of travel? (Otherwise, write N/A)
*
Arrival and return dates for each area
Any public event attended in the last 15 days? (Otherwise, write N/A)
*
Please state whether you've experienced/are experiencing the following
*
Rows
YES
NO
Fever
1
2
Tiredness
3
4
Headache
5
6
Cough
7
8
Breathing Difficulty
9
10
Gastrointestinal Symptoms
11
12
Loss of sensation of smell
13
14
I agree that the information provided in this form is true and correct to the best of my knowledge and understand that any dishonest answer may have serious legal and public health implications under RA 11332.
*
Yes
Branch
*
Please Select
SM Marilao
Date
*
 /
Month
 /
Day
Year
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Signature
Submit
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