HEALTH DECLARATION Runny Nose or Sneezing NO

Due to the recent worldwide outbreak of COVID-19, Cough and colds NO

St. Luke's Medical Center Extension Clinic would like to
ensure that our patients/customers and employees Loss of smell and/or taste NO
are safe from exposure to the disease. In line with this,
we are requesting all patients, including companions
Eye discharge NO
and visitors, to complete this form.

Skin rash or discoloration of toes/fingers NO

The data that you provide is strictly confidential and used for hospital reference only.
Loss of speech or movement NO
Name: WILMA VERGARA USI Age: 39 Sex: FEMALE Contact No.: 0999-520-5669 I am a [ ]
Patient [ ] Visitor [ ] Companion [ ] Others___________
Please tick an answer for every question item NO YES
I agree that the information provided in this document is true and correct to the best of my
Have you been tested for COVID-19 in the last 2 weeks? NO knowledge and understand that any dishonest answers may have serious legal and public
Date swabbed: Result (if available): health implications under RA 11332.

Have you been evaluated as Probable or Suspected for NO I declare that all information disclosed above is TRUE and CORRECT.
COVID-19? If YES, when did your quarantine start?
Signature: __________________________________ Date:_______________________
Did you have any travel history in the past 14 days? NO
If YES, when and where? Approved entry by: ___________________________ Referred to:__________________
(Name & signature of associate)
Did you come in close contact or are you staying in the same close NO
environment with someone who is a confirmed COVID-19 case? [ ] HEALTH DECLARATION
Relative [ ] Workplace [ ] Household When: _____________
Due to the recent worldwide outbreak of COVID-19,
Have you experienced any of the following symptoms in NO YES Date
Experienced St. Luke's Medical Center Extension Clinic would like to
the last two weeks?
ensure that our patients/customers and employees
Fever (>38°C) are safe from exposure to the disease. In line with this,
NO
we are requesting all patients, including companions
and visitors, to complete this form.
Diarrhea, Nausea, or Vomiting NO

Shortness of breath or other respiratory symptoms NO The data that you provide is strictly confidential and used for hospital reference only.

Other respiratory symptoms: NO Name: WILMA VERGARA USI Age: 39 Sex:FEMALE Contact No.: 0999-520-5669 I am a [ ]
Patient [ ] Visitor [ ] Companion [ ] Others___________
Headache NO Please tick an answer for every question item NO YES

Joint Pain or Muscle Pain NO Have you been tested for COVID-19 in the last 2 weeks? NO
Date swabbed: Result (if available):
Flu-like symptoms such as: NO
Chills or repeated shaking with chills Have you been evaluated as Probable or Suspected for NO
COVID-19? If YES, when did your quarantine start?
Body aches NO
Did you have any travel history in the past 14 days? NO
If YES, when and where?
Sore throat NO
 (Name & signature of associate)
Did you come in close contact or are you staying in the same close NO
environment with someone who is a confirmed COVID-19 case? [ ]
Relative [ ] Workplace [ ] Household When: _____________

Have you experienced any of the following symptoms in NO YES Date

the last two weeks? Experienced

Fever (>38°C) NO

Diarrhea, Nausea, or Vomiting NO

Shortness of breath or other respiratory symptoms NO

Other respiratory symptoms: NO

Headache NO

Joint Pain or Muscle Pain NO

Flu-like symptoms such as: NO

Chills or repeated shaking with chills

Body aches NO

Sore throat NO

Runny Nose or Sneezing NO

Cough and colds NO

Loss of smell and/or taste NO

Eye discharge NO

Skin rash or discoloration of toes/fingers NO

Loss of speech or movement NO

I agree that the information provided in this document is true and correct to the best of my
knowledge and understand that any dishonest answers may have serious legal and public
health implications under RA 11332.

I declare that all information disclosed above is TRUE and CORRECT.

Signature: __________________________________ Date:_______________________

Approved entry by: ___________________________ Referred to:__________________