Contact Tracing and Health Declaration Form

Please placemark your response. (Lagyan ng marka ang angkop na sagot)

Are you experiencing:

(Nakakaranas ka ba:)

Fever (lagnat)
Cough and/or colds (ubo at/o sipon)
Body Pains (pananakit ng katawan)
Sore throat (pananakit ng lalamunan/masakit lumunok)

Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1 meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na probable o kumpirmadong pasyente na may COVID-19 mula sa isang metrong distansya o mas malapit pa at tumagal ng higit sa 15 minuto sa nakalipas na 14 araw?)

Have you provided direct care for a patient with probable or confirmed COVID-19 case without using proper personal protective equipment for the past 14 days?  (Nag-aalaga ka ba ng probable o kumpirmadong pasyente na may COVID-19 ng hindi nakasuot ng tamang personal protective equipment as nakalipas na 14 araw?)

Have you traveled outside the Philippines in the last 14 days?  (Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)

Have you traveled outside in the current City/Municipality where you reside?  (ikaw ba ay nagbyahe sa labas ng iyong lungsod/munisipyo?)

Reason of visit:
Please check if you are new or existing customer.

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