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Health Declaration Form

This document is a health declaration form used by Saint Louis University's medical clinic. It requires visitors, employees, and students to answer questions about their recent travel history, exposure to COVID-19, and any COVID-19 symptoms. They must declare that their answers are true and acknowledge legal penalties for providing false information. Based on the answers provided, a triage officer will determine any necessary actions and provide a triage sticker to allow entry to the clinic.

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103 views1 page

Health Declaration Form

This document is a health declaration form used by Saint Louis University's medical clinic. It requires visitors, employees, and students to answer questions about their recent travel history, exposure to COVID-19, and any COVID-19 symptoms. They must declare that their answers are true and acknowledge legal penalties for providing false information. Based on the answers provided, a triage officer will determine any necessary actions and provide a triage sticker to allow entry to the clinic.

Uploaded by

Sunnee Bannee
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Document Code FM-MEC-023

Revision No. 00
Effectivity FEB 01, 2021
SAINT LOUIS UNIVERSITY page 1 of 1

MEDICAL CLINIC
HEALTH DECLARATION FORM SLU EMPLOYEE
VISITOR
STUDENT
NAME: DATE: ASE
HOME ADDRESS:
AGE: CONTACT NO.: DEP’T. / DESTINATION:
INSTRUCTION: Answer the following questions with Yes or No. TEMPERATURE
Please tick or check ( / ) your answers.
1. Is the place you are residing at, included in the COVID-19 High Risk areas YES NO
or currently on LOCKDOWN? ( ) ( )
2. Did you travel outside Baguio in the last 14 days? YES NO
If YES please specify all places_____________________________________ ( ) ( )
3. In the past two weeks, have you: YES NO
a. Had any known exposure to a confirmed COVID-19 patient? ( ) ( )

4. Have you tested POSITIVE for COVID-19 in the last 30 days? YES NO
( ) ( )
5. MEDICAL HISTORY: Have you been sick or experienced any of the
following in the last 14 days? YES NO
a. FEVER (LAGNAT) ( ) ( )
b. COUGH (UBO) ( ) ( )
c. COLDS (SIPON) ( ) ( )
d. SORE THROAT (PANANAKIT NG LALAMUNAN) ( ) ( )
e. DIFFICULTY IN BREATHING (HIRAP SA PAGHINGA) ( ) ( )
f. DIARRHEA (MADALAS NA PAGDUMI) ( ) ( )
g. OTHERS: Do you have history of Hypertension, Diabetes Mellitus, Heart ( ) ( )
disease, Lung Disease etc. Others please write it on the space provided. ________
For FEMALES: Are you PREGNANT? ( ) ( )
DECLARATION: I hereby certify that the above information is true and complete. I understand
that my failure to answer, or any false or misleading information given by me may be used as
a ground for the filing of cases against me under Articles 171 and 172 of the Revised Penal
Code of the Philippines, or Republic Act No. 11332, otherwise known as the “Law on Reporting
of Communicable Disease”. (Ako ay nagpapatunay na ang mga impormasyon na aking binigay
ay totoo at kumpleto. Naiintindihan ko na ang kung anumang maling impormasyon ay maaring ______
maging dahilan para sa paghain ng kasong criminal laban sa akin sa ilalalim ng Article 171 at SIGNATURE
172 ng Revised Penal Code o sa ilalim ng Republic Act No. 11332).
ACTIONS TO BE DONE (TO BE FILLED UP BY THE TRIAGE OFFICER)
NAME AND SIGNATURE OF TRIAGE OFFICER

PLEASE SUBMIT THIS FORM THEN GET A TRIAGE STICKER. PUT STICKER ON CHEST/VISIBLE AREA.
ONLY ONE STICKER SHOULD BE VISIBLE.

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