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Date of Birth

Weight (KG)

Height (FT)

Blood Pressure

Temperature (C)

Detailed Contract Tracing:

1. Did you experience any of the following in the past 14 days?

Sore Throat

Cough or Colds

Headache or Body Pains

Fever

Shortness of Breath

2. Do you have close contact with or exposure to any of the following in the past 14 days?

A suspected or confirmed COVID-19 case

Someone with fever, cough, colds, or sore throat

3. Did you travel to or visit any of the following in the past 14 days?

Another country.

An area in the Philippines, aside from your area of residence, that has confirmed COVID-19 cases.

A hospital or health care facility that has confirmed COVID-19 cases.

4. Are there suspected or confirmed COVID-19 cases in your area of residence?