Daily Health Monitoring Sheet
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Hour Minutes
AM
PM
AM/PM Option
Name
*
First Name
Last Name
BODY TEMPERATURE
*
(in Degree Celsuis °C)
Sex
Please Select
Male
Female
Age
Residence Address
Nature of Visit
Please Select
Official
Personal
(If Official, please fill in company name and address)
Are you experiencing:
Sore throat
Body pain
Headache
Fever for the past few days
Cough
Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?
Please Select
YES
NO
Have you had any contact with anyone with fever, cough, colds and sore throat in the past 2 weeks?
Please Select
YES
NO
Have you travelled outside of your state in the last 14 days?
Please Select
YES
NO
Have you travelled to any area in NCR aside from your home?
Please Select
YES
NO
If yes, please specify
Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: