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Health Declaration Form English

This 3 sentence summary provides the key details from the Health Declaration Form: The form collects personal information such as name, age, occupation and travel history over the past 30 days from the individual filling it out. It asks if the person has experienced any symptoms like fever, cough or difficulty breathing recently or visited any hospitals, animal markets or slaughterhouses. By signing, the individual verifies the information is true and correct and allows the medical center to use it in accordance with local law.

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DoyTan
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116 views

Health Declaration Form English

This 3 sentence summary provides the key details from the Health Declaration Form: The form collects personal information such as name, age, occupation and travel history over the past 30 days from the individual filling it out. It asks if the person has experienced any symptoms like fever, cough or difficulty breathing recently or visited any hospitals, animal markets or slaughterhouses. By signing, the individual verifies the information is true and correct and allows the medical center to use it in accordance with local law.

Uploaded by

DoyTan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Reason for Travel:

______ Work/Business
HEALTH DECLARATION FORM ______ Vacation
Instructions: Please accomplish this checklist ______ Home
truthfully, for you and your family/community’s
safety and protection. Thank you ______ Education

Part 1: Others: ________________________________

Name: Name and Address of Hotel stayed in:

________________________________________ _______________________________________

Gender: ____M ____F _______________________________________

Temp: _________________ In the past 30 days:

Address: _________________________________ Did you visit any health worker, hospital, clinic?

_________________________________________ _____ Yes (Specify) ________________________

_________________________________________ _____ No

Birthday: _________________________________ Did you visit any zoo, poultry farm, animal market,
slaughter house?
Age: __________
_____ Yes (Specify) ________________________
Mobile/Telephone Number: __________________
_____ No
Email Address: ____________________________
Did you take any Fever Medications?
Occupation:
________________________________________ _____ Yes (Specify) ________________________

Part 2: _____ No

Reason for Consultation/Admission: ____________ Did you take any Cough Medications?

_________________________________________ _____ Yes (Specify) ________________________

Foreign Countries or Places in the Philippines you _____ No


have visited/worked in the past 30 days, specify Do you have any household members, close
date of departure and arrival: friends, relatives you have met lately having fever,
_________________________________________ cough, and/or any respiratory problems?

_________________________________________ _____ Yes (Specify) ________________________

_________________________________________ _____ No

Have you been sick in the past 30 days? Do you have any relatives, friends, neighbors that
you have met lately who arrived from any other
_____Yes, (Describe Condition): country or city?
_________________________________________ _____ Yes (Specify) ________________________
______No _____ No
Did you have any of the following in the past 30
days:
The information I have provided herein is true and
____ Fever ____ Colds ____ Cough correct. I authorize EYV Medical Corporation to use
this information in accordance with Philippine law. If
____ Sore Throat ____ Diarrhea
caught providing wrong or dishonest information, I
____ Difficulty in Breathing ____ Body Weakness will be held accountable for my actions.

Part 3 _______________________________________
In the past 30 days did you travel by: Printed Name & Signature (Patient / Guardian)
_____ Air (Specify) _________________________ Date: ________________________
_____ Land (Specify) _______________________
_____ Sea (Specify) ________________________

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