Health Checklist Form First Name* Last Name* Address Temperature* Cellphone* Age* Sex* MaleFemale 1. Are you experiencing? Colds YesNo Body Pains YesNo Headache YesNo Fever for the past days? YesNo 2. Have you been in contact or stayed in a close environment with a person potentially exposed to COVID-19 and/or confirmed COVID-19 person or anyone related or had contact with a confirmed COVID-19 patient (friend, relative, colleague, neighbor)? YesNo 3. Did you have any contact with someone with fever, cough, colds, sore throat in the past 2 weeks? YesNo 4. Have you travelled outside the Philippines in the last 14 days? YesNo 5. Have you travelled to any area in NCR aside from your home and office in the last 14 days? YesNo 6. List the places you've been to yesterday ADDITIONAL SAFETY & HEALTH CHECKLIST 1. How many are you in the house? 2. Is any one currently ill in the household? YesNo If yes, what illness? 3. How long has the symptom/s existed? 4. Has a medical worker/ doctor examined the patient? YesNo 5. Can you give an overview of the examination result? YesNo 6. Do you yourself manifest the following same symptoms: YesNo Fever YesNo Cough YesNo Headache YesNo Muscle Aches YesNo Sore Throat YesNo Loss of Taste or Smell YesNo Chills YesNo Nausea YesNo Diarrhea YesNo Vomiting YesNo Difficulty breathing or shortness of breath YesNo 7. Have you attended a mass gathering/meeting in the last 14 days? YesNo If yes, where and when? 8. Did anyone from your household attended a mass gathering/meeting in the last 14 days? YesNo If yes, where and when? I certify that as of today, I am submitting this Health Checklist Form voluntarily and with full knowledge and understanding of its safety purpose. It is also my genuine desire to preserve the good health and well being of everyone in my workplace and home. Δ
