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    Health Checklist

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    U N K O W N U N k o w n
    This document is a health checklist that collects information from patients such as name, age, residence, reason for visit, travel history, and symptoms. It asks questions to screen for COVID-19 exposure and symptoms. It authorizes the health system to collect the data for controlling COVID-19 infection, and notes the patient is required to provide truthful information under relevant privacy and emergency laws.

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    Health Checklist

    Uploaded by

    U N K O W N U N k o w n
    28 views1 page
    This document is a health checklist that collects information from patients such as name, age, residence, reason for visit, travel history, and symptoms. It asks questions to screen for COVID-19 exposure and symptoms. It authorizes the health system to collect the data for controlling COVID-19 infection, and notes the patient is required to provide truthful information under relevant privacy and emergency laws.

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    This document is a health checklist that collects information from patients such as name, age, residence, reason for visit, travel history, and symptoms. It asks questions to screen for COVID-19 exposure and symptoms. It authorizes the health system to collect the data for controlling COVID-19 infection, and notes the patient is required to provide truthful information under relevant privacy and emergency laws.

    Copyright:

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

    Health Checklist

    Uploaded by

    U N K O W N U N k o w n
    This document is a health checklist that collects information from patients such as name, age, residence, reason for visit, travel history, and symptoms. It asks questions to screen for COVID-19 exposure and symptoms. It authorizes the health system to collect the data for controlling COVID-19 infection, and notes the patient is required to provide truthful information under relevant privacy and emergency laws.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Health Checklist Temperature:

     Name:  Gender:  Age:


     Residence:
     Nature of Visit: Medical:
    Please check one Personal:
    Official: If official, fill-in company details below

    Company Name:
    Company
    Address:

    Yes No
     1. Are you experiencing: a. Sore throat
    (nakakaranas ka ba (pananakit ng lalamunan / masakit
    ng:) lumunok)
    b. Body pains
    (pananakit ng katawan)
    c. Headache
    (pananakit ng ulo)
    d. Fever for the past few days
    (Lagnat sa nakalipas na mga araw)

     2. Have you worked together or stayed in the same close environment of a


    confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao
    na kumpirmadong may COVID-19 / may impeksyon ng coronavirus?)

     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?)
     4. Have you travelled outside of the Philippines in the last 14 days?
    (Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)
     5. Have you travelled to any area in NCR aside from your home?
    (Ikaw ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong
    bahay?) Specify(Sabihin kung saan): ___________________________________

    I hereby authorize NATIONWIDE HEALTH SYSTEMS BAGUIO, INC., to collect and process the data
    indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that
    my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am required
    by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

    Signature: Date:

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