LAGUNA UNIVERSITY



HEALTH DECLARATION SURVEY FORM

Note: This form shall be accomplished by all Laguna University visitors and clients.
Last Name:  
First Name:  
Middle Name:  
Address:  
Age:  
Gender:  
Contact Number:  
Email Address:  
Purpose of visit: `
 
 
 
 
 
  
YES NO
Sore throat
Cough
Colds
Body Pains
Headache
Fever
Difficulty of Breathing
YES NO
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)