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Health Declaration Form

The Health Declaration Form collects personal, travel, and health information to assess exposure to contagious diseases. It includes sections for symptoms, medical history, and vaccination status. The form requires a declaration of the accuracy of the provided information, with a signature and date.

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reidimapasok
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12 views1 page

Health Declaration Form

The Health Declaration Form collects personal, travel, and health information to assess exposure to contagious diseases. It includes sections for symptoms, medical history, and vaccination status. The form requires a declaration of the accuracy of the provided information, with a signature and date.

Uploaded by

reidimapasok
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

HEALTH DECLARATION FORM

1. Personal Information C. Exposure History


Full Name: ______________________________  Have you been in close contact with a person
Date of Birth: ____________________________ diagnosed with a contagious disease in the past
Gender: ________________________________ 14 days?
Nationality: _____________________________ ☐ Yes ☐ No
ID Number: _____________________________
 Have you tested positive for any infectious
Phone Number: __________________________ disease in the past 14 days?
Email Address: ___________________________ ☐ Yes ☐ No
Home Address: __________________________
If yes, please provide details:

2. Travel Information (if applicable) 4. Vaccination Status

 Countries visited in the last 14–30 days:  Are you vaccinated? ☐ Yes ☐ No
_______________________________________
 Vaccine Name: __________________________
 Date of Arrival: __________________________
 Number of Doses Received: ________________
 Flight/Transport Number: __________________
 Date of Last Dose: ________________________
 Purpose of Travel: ________________________

3. Health Information

A. Symptoms (check if applicable):

☐ Fever
☐ Cough
☐ Shortness of breath
☐ Sore throat
☐ Loss of taste or smell
☐ Fatigue
☐ Headache
☐ Diarrhea
☐ Other: _______________________
5. Declaration
B. Medical History (check if applicable):
I hereby declare that the information provided above is
☐ Diabetes true and correct to the best of my knowledge. I
☐ Hypertension understand that providing false information may result in
☐ Heart Disease penalties according to applicable laws and regulations.
☐ Lung Disease
☐ Asthma Signature: ___________________________
☐ Recent Surgery Date: _______________________________
☐ Other: _______________________

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