Scribd Logo
Upload

Welcome to Scribd!

  • 121 views

    In The Past1 4 Da S, Did You Have Any of Thefollowing:: Sheet

    Uploaded by

    Leoni Franc
    This document contains a patient data sheet for an individual seeking diagnostic testing. It collects personal details like name, birthdate, contact information, and health declaration. The health declaration asks about any recent COVID-19 symptoms, medications, travel history, exposure risks, and past testing. It notes that information provided will be reported as required by law and seeks consent to release results to authorized parties according to the patient's situation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    In The Past1 4 Da S, Did You Have Any of Thefollowing:: Sheet

    Uploaded by

    Leoni Franc
    121 views1 page
    This document contains a patient data sheet for an individual seeking diagnostic testing. It collects personal details like name, birthdate, contact information, and health declaration. The health declaration asks about any recent COVID-19 symptoms, medications, travel history, exposure risks, and past testing. It notes that information provided will be reported as required by law and seeks consent to release results to authorized parties according to the patient's situation.

    Original Description:

    Original Title

    HPD_F_1066-Patient-Data-Sheet-FILL-UP-COLORED-FINAL-converted

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains a patient data sheet for an individual seeking diagnostic testing. It collects personal details like name, birthdate, contact information, and health declaration. The health declaration asks about any recent COVID-19 symptoms, medications, travel history, exposure risks, and past testing. It notes that information provided will be reported as required by law and seeks consent to release results to authorized parties according to the patient's situation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    121 views1 page

    In The Past1 4 Da S, Did You Have Any of Thefollowing:: Sheet

    Uploaded by

    Leoni Franc
    This document contains a patient data sheet for an individual seeking diagnostic testing. It collects personal details like name, birthdate, contact information, and health declaration. The health declaration asks about any recent COVID-19 symptoms, medications, travel history, exposure risks, and past testing. It notes that information provided will be reported as required by law and seeks consent to release results to authorized parties according to the patient's situation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    PATIENT DATA SHEET H I PRECi Si o n Hi-Precision ADVANCED

    diagnostics Diagnostics PLUS LAB SOLUTIONS


    by Hi-Precision Diagnostics

    Date: Time: AIWPM Thermal Scan temperature:

    ' PERSONAL DETAILS


    LAST NAME FIRST NAME MIDDLE NAME PHYSICIAN’S NAME (or indicate N/A if none)

    BIRTHDATE (MM-DD-YYYY) TEST REQUEST/S /if applicable)

    AGE ) SEX ATBIRTH Male Female

    CONTACT NO/S

    RESIDENCE ADDRESS

    HEALTH DECLARATION
    In the past1 4 da s, did you have any of the following: NO YES
    1. Symptoms:
    A. Fever ( a 37.5OC)
    Dnte of first day of symptoms:
    B. Cough
    C. Colds
    D. Shortness of breath Date of last day of symptoms:
    E. Sore throat
    F. Influenza-like symptoms (headache, muscle and joint pain, diarrhea, lack of sense of smell or taste)
    2. History of intake of antibiotics or medications for cough, colds, fever (past 3 c/ays only)
    3. Travel to a country outside the Philippines
    4. Household member diagnosed with COVID-19 Date of lastexposure:
    5. Contact or exposure to a probable or confirmed caae
    Oef/n/tion of contact or ex osure ol'the followin • Direct care for a patient without using proper PPE
    • Face-to-face contact within 1 meter and for more than 15 minutes • Other situations as indicated by local risk assessments
    • Direct physical contact as dictated by the Local Government Unit (LGU)
    6. History of COVID-19 infection Date swabbed:
    7. History of total antibody t3-} OR IgM t-I-) and IgG t-) rapid antibody result Date tested:
    Reason:
    8. History of confinement in the hospital
    Date of discharge:

    Please note that in compliance with RA 11332 or the Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern
    Act, those who will be classified as possible, suspect and probable COVID cases will be reported to Regional Epidemiology and Surveillance
    Units (RESU). The same act also requires that the information that you provide regarding your health condition and possible exposure are
    true.
    As a private client, I understand that I must personally claim or access my results online. If I am unable to personally claim my results, I authorize
    the release of my results via the following delivery modes:
    by proxy pick-up, s/he must present an authorization letter with an attached copy of my and his/her valid I.D.
    by sending the physical copy to

    As a corporate client, I understand that I must abide by the instructions given to me by my employer / company / HMO / insurance agent / broker
    regarding release of results. When required, I also give my consent and allow HPD to post online and/or forward all the results of my medical
    examination including, but not limited to laboratory and ancillary examinations, to my employer / company / HMO / insurance agent / broker

    Hi-Precision Diagnostics respects and puts utmost priority on the confidentiality of your personal information. Please read our Privacy Policy to
    understand how we protect and use your personal information in accordance with Data Privacy Act of 2012, its Implementing Rules and Regulations,
    other issuances of the National Privacy Commission and other relevant laws of the Philippines. You may access our Privacy Policy at our branches and
    through our website at hi-precision.com.ph.
    By signing this registration form, you confirm that you accept our processing of your information and agree to our Privacy Policy.

    Patient or Legal Guardian’s* Signature over Printed Name / Date Signed Triage Sta0

    */Vofe: Ifsigning as/epa/ guaAian forminororincapacitated patient,p/easeindicate fherelationship topatient.

    l”t)lIM CRI-A"I”l:11: August 21, 2020


    l•OkM ltLVlSlON: 2

    You might also like