DCBESMNHS HEALTH DECLARATION FORM TEMPERATURE: DCBESMNHS HEALTH DECLARATION FORM TEMPERATURE:

NAME & SECTION: ________________________ DATE & TIME:___________ NAME & SECTION: ________________________ DATE & TIME:___________
COMPLETE ADDRESS:______________________ MOBILE NO.____________ COMPLETE ADDRESS:______________________ MOBILE NO.____________
Put a check mark on the appropriate column of your response. Put a check mark on the appropriate column of your response.

YES NO YES NO
1. Are you experiencing the following? 1. Are you experiencing the following?
(nakakaranas k a ba ng alinman sa mga sumusunod.) (nakakaranas k a ba ng alinman sa mga sumusunod.)
a. Sore throat (pananakit o pamamaga ng lalamunan) a. Sore throat (pananakit o pamamaga ng lalamunan)
b. Body Pains (pananakit ng katawan) b. Body Pains (pananakit ng katawan)
c. Headache (pananakit ng ulo) c. Headache (pananakit ng ulo)
d. Fever for the past few days (lagnat sa nakalipas na mga d. Fever for the past few days (lagnat sa nakalipas na mga
araw) araw)
2. Have you stayed in the same close environment of a 2. Have you stayed in the same close environment of a
confirmed COVID-19 case? confirmed COVID-19 case?
(May nakasama ka ba na kumpirmadong may COVID-19/may (May nakasama ka ba na kumpirmadong may COVID-19/may
impeksyon ng coronavirus?) impeksyon ng coronavirus?)
3. Have you had any contact with anyone with fever, cough, 3. Have you had any contact with anyone with fever, cough,
colds, and sore throats in the past 2 weeks? colds, and sore throats in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o (Mayroon ka bang nakasama na may lagnat, ubo, sipon o
sakit ng lalamunan sa nakalipas na dalawang lingo?) sakit ng lalamunan sa nakalipas na dalawang lingo?)
4. Have you traveled outside the current city/municipality 4. Have you traveled outside the current city/municipality
where you reside? where you reside?
(Ikaw ba ay nagbyahe sa labas ng inyong lungsod/munisipyo?) (Ikaw ba ay nagbyahe sa labas ng inyong lungsod/munisipyo?)
If yes, specify which city/municipality you went If yes, specify which city/municipality you went
to_____________________________ to_____________________________
This form and all information you provide will be kept confidential and secured following appropriate security measures, This form and all information you provide will be kept confidential and secured following appropriate security measures,
and will only be disclosed to proper authorities for purposes of contact tracing following the DOH protocols. The and will only be disclosed to proper authorities for purposes of contact tracing following the DOH protocols. The
information collected from you shall be securely disposed of after 21 days from date of collection. information collected from you shall be securely disposed of after 21 days from date of collection.
Signature/Lagda: _________________________ Signature/Lagda: _________________________

DCBESMNHS HEALTH DECLARATION FORM TEMPERATURE: DCBESMNHS HEALTH DECLARATION FORM TEMPERATURE:

NAME & SECTION: ________________________ DATE & TIME:___________ NAME & SECTION: ________________________ DATE & TIME:___________
COMPLETE ADDRESS:______________________ MOBILE NO.____________ COMPLETE ADDRESS:______________________ MOBILE NO.____________
Put a check mark on the appropriate column of your response. Put a check mark on the appropriate column of your response.

YES NO YES NO
1. Are you experiencing the following? 1. Are you experiencing the following?
(nakakaranas k a ba ng alinman sa mga sumusunod.) (nakakaranas k a ba ng alinman sa mga sumusunod.)
a. Sore throat (pananakit o pamamaga ng lalamunan) a. Sore throat (pananakit o pamamaga ng lalamunan)
b. Body Pains (pananakit ng katawan) b. Body Pains (pananakit ng katawan)
c. Headache (pananakit ng ulo) c. Headache (pananakit ng ulo)
d. Fever for the past few days (lagnat sa nakalipas na mga d. Fever for the past few days (lagnat sa nakalipas na mga
araw) araw)
2. Have you stayed in the same close environment of a 2. Have you stayed in the same close environment of a
confirmed COVID-19 case? confirmed COVID-19 case?
(May nakasama ka ba na kumpirmadong may COVID-19/may (May nakasama ka ba na kumpirmadong may COVID-19/may
impeksyon ng coronavirus?) impeksyon ng coronavirus?)
3. Have you had any contact with anyone with fever, cough, 3. Have you had any contact with anyone with fever, cough,
colds, and sore throats in the past 2 weeks? colds, and sore throats in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o (Mayroon ka bang nakasama na may lagnat, ubo, sipon o
sakit ng lalamunan sa nakalipas na dalawang lingo?) sakit ng lalamunan sa nakalipas na dalawang lingo?)
4. Have you traveled outside the current city/municipality 4. Have you traveled outside the current city/municipality
where you reside? where you reside?
(Ikaw ba ay nagbyahe sa labas ng inyong lungsod/munisipyo?) (Ikaw ba ay nagbyahe sa labas ng inyong lungsod/munisipyo?)
If yes, specify which city/municipality you went If yes, specify which city/municipality you went
to_____________________________ to_____________________________
This form and all information you provide will be kept confidential and secured following appropriate security measures, This form and all information you provide will be kept confidential and secured following appropriate security measures,
and will only be disclosed to proper authorities for purposes of contact tracing following the DOH protocols. The and will only be disclosed to proper authorities for purposes of contact tracing following the DOH protocols. The
information collected from you shall be securely disposed of after 21 days from date of collection. information collected from you shall be securely disposed of after 21 days from date of collection.
Signature/Lagda: _________________________ Signature/Lagda: _________________________