HEALTH DECLARATION FORM First Name:* Last Name:* Address:* Mobile Number:* Sex: Male Female TRAVEL HISTORY: Arrival Date: Flight No: Port of Origin: Seat No.: Countries visited for the past fourteen (14) days: Country No. 1 CountryNo.2 CountryNo.3 Cities / municipalities in the Philippines visited for the past fourteen (14) days: City/Municipalities 1 City/Municipalities 2 City/Municipalities 3 PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT PRESENT OR DURING THE PAST FOURTEEN (14) DAYS* Fever Cough Headache Difficulty of Breathing Sore Throat Body Weakness Unexplained Bruising or Bleeding Severe Diarrhea None Did you visit any hospital, clinic, or nursing home in the past fourteen (14) days? YES NO Have you been in contact with a suspected or confirmed SARS – COV (COVID-19) patient for the past fourteen (14) days? YES NO Do you have any household member/s, or close friend/s who have met a person currently having fever, cough and/or respiratory problems? YES NO Have you undertaken any CoVID Test? YES NO Submit
