LU:AD-FO-13 rev.0 10122020
Medical and Dental Clinic
Laguna Sports Complex, BRGY. Bubukal, Santa Cruz, Laguna
Tel. No. (049) 576-4359
HEALTH DECLARATION SURVEY FORM
Note: This form shall be accomplished by all Laguna University visitors and clients.
Purpose of visit:
pick up / delivery
1. Body Temperature:
2. In the last 14 days up to present, have you experienced these symptoms?
Difficulty of Breathing
3. If your answer is YES to any symptoms listed above, have you had exposure 2 days before or 14 days from the onset of these symptoms to a confirmed or probable case?
Face- to- face contact with a confirmed COVID-19 case with in 1 meter and for more than 15 minutes
Direct physical contact with a confirmed COVID-19 case
Direct care for a patient with a probable/confirmed COVID-19 case with or without using proper personal protective equipment (PPE)
4. In the last 14 days, have you travelled in another province, city or country?
Please specify the place:
I agree to the collection and processing of my data for the purpose of effecting control of any infectious diseases. 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.