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Health Checklist

Name:
Residence:
Temperature:
Gender:
M F
Age:
Nature of Visit:
Official Personal
Company Name:
Company Address:
1. Are you experiencing (Nakakaranas ka ba ng):
A. Sore throat (Pananakit ng lalamunan/Masakit lumunok)
Yes No
B. Body Pains (Pananakit ng Katawan)
Yes No
C. Headache (Pananakit ng ulo)
Yes No
D. Fever for the past few days (Lagnat sa mga nakalipas na mga araw)
Yes No
2. Have you worked together or stayed in the same close environment of confirmed COVID-19 case?
(May nakasama ka ba o nakatrabhong tao na kumpirmadong may COVID-19/May impeksyon ng corona virus?)
Yes No
3. Have you had any contact with anyone with fever, cough, colds and sore throat in the past 2 weeks?:
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas ng dalawang (2) lingo?)
Yes No
4. Have you travelled outside of the Philippines in the last 14 days?
(Ikaw ba ay nagbyahe sa labas ng Pilipinas na 14 araw?)
Yes No
5. Have you travelled to any area in NCR aside from your home?
(Ikaw ba ay nagpunta sa ibang parte ng NCR or Metro Manila bukod sa iyong bahay? Specify (Sabihin kung saan)
Yes No