Health Assessment

Please answer the following questions then save.

I. BASIC INFORMATION

Type

Fullname

Workbase

Address

Contact number

Purpose

II. SYMPTOMS OF COVID-19

Select YES or NO. In the past 14 days, have you had any of the following?

Symptoms

Fever

Cough

Colds

Shortness or Difficulty of Breathing

Sore Throat

Vomiting

LBM

Loss of Taste

Loss of Smell

Body Pain or Malaise

Conjunctivitis

Severe headache

Skin Rashes or Discoloration of Fingers

Chest Pain or Pressure

Loss of Speech or Movement

Do you fil ill today?

Temperature at the moment? (degree celsius)

III. EXPOSURE

Select YES or NO. In the past 14 days, have you had exposure to someone with any of the following?

a.) Confirmed COVID-19 case?

b.) Being monitored for possible COVID-19 infection (PUM/PUI)?

c.) Has visited hospitals, isolation center, prison, funeral parlor, and other high-risk areas, OR have you personally visited any of these places (where and when)?

d.) With Illness and is experiencing at least one of the stated COVID-19 symptoms (if any, what illness)?

e.) Newly arrived individual from other places (OFW, Balikbayan, Visitor, Locally Stranded)?

IV. PROXIMITY AND HISTORY

Select YES or NO.

a.) Is there a documented confirmed COVID-19 case in your Barangay for the last 14 days (if any, is it near your house? estimate distance)?

b.) Have you traveled to any places other than your usual work-house routine or other than your current residence in the past 14 days (if any, when and where)?

c.) Have you attended any occasions which involved gatherings (with attendees other than from the same household) like fiestas, parties, baptism, weddings, outings, videoke, discos, road trips, wakes/burials, and other held in communal places in the past 14 days (what and when)?

d.) Have you lived with somebody who was quarantined or infected with this disease for the past 14 days(when)?

V. OTHER QUESTIONS

Select YES or NO.

a.) Do you have yellowish discoloration of skin?

b.) Are there any abnormal discharges in your eyes, nose, mouth, and ears?

c.) Do you have any unhealed wounds in the body?

d.) Other than stated, is there anything significant you'd like to share with us about your current health status (what)?

d.) Are ALL of your answers here TRUE and CORRECT?

I. BASIC INFORMATION

I. IMPORMASYON

II. SYMPTOMS OF COVID-19

II. SIMTOMAS SA COVID-19

III. EXPOSURE

III. EXPOSURE

IV. PROXIMITY AND HISTORY

IV. KADUL-ON SA KASO UG MGA HISTORY

V. OTHER QUESTIONS

V. DUGANG NGA PANGUTANA