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HEALTH DECLARATION SHEET 2022 (Students)

This document is a COVID-19 health declaration form containing questions for students about their symptoms, travel history, attendance at gatherings, mask usage, and exposure to COVID-19. It collects information on fever, cough, colds, sore throat, malaise, muscle pain, diarrhea, and loss of smell or taste. It also asks if the student has traveled outside the country or locality in the past 14 days, attended gatherings of various sizes, consistently worn a face mask, and been exposed to anyone suspected of or diagnosed with COVID-19.

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Mark Anthony Arenas Gioketo
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39 views1 page

HEALTH DECLARATION SHEET 2022 (Students)

This document is a COVID-19 health declaration form containing questions for students about their symptoms, travel history, attendance at gatherings, mask usage, and exposure to COVID-19. It collects information on fever, cough, colds, sore throat, malaise, muscle pain, diarrhea, and loss of smell or taste. It also asks if the student has traveled outside the country or locality in the past 14 days, attended gatherings of various sizes, consistently worn a face mask, and been exposed to anyone suspected of or diagnosed with COVID-19.

Uploaded by

Mark Anthony Arenas Gioketo
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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COVID - 19 HEALTH DECLARATION FORM

Name: __________________________________________________________________________________________
Grade Level/Section: ________________________ Date: _______________________________________

1. Have you experienced any of the following symptoms? (Check all that apply and date of start and end.)

SYMPTOMS YES NO DATE STARTED DATE ENDED

Fever (lagnat temp 37.6 C pataas)


Cough (ubo)
Colds (sipon)
Sore throat (namamagang lalamunan)
Malaise (panghihina)
Muscle pain (pananakit ng kalamnan)
Diarrhea (pagtatae)
Loss of smell or taste
(pagkawala ng pang-amoy o panlasa)

2. Have you travelled or have you been in close contact with anyone who has travelled outside of the country
(i.e. returning OFW), or outside of your locality in the past 14 days?

YES _____ If YES, from where? ________________________


NO _____

3. Have you attended any gatherings in the past 14 days with these number of people (check all applicable)?

GROUP SIZE YES NO WHEN


10
20
30
50 at mas higit pa
100 at mas higit pa

4. Have you consistently worn a face mask in going outside of the home or talking to visitors?

YES ______ NO _______

5. Have you been exposed to or a close contact with anyone suspected of or diagnosed of having COVID -
19?

YES _____ Date of exposure (if YES): _________________________


NO _____

_____________________________________________ ________________________________________
SIGNATURE OVER PRINTED NAME DATE

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