LU:AD-FO-12 rev.0 10122020
LAGUNA UNIVERSITY
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.
Last Name:
First Name:
Middle Name:
Address:
Age:
Gender:
Male
Female
Contact Number:
Email Address:
Purpose of visit:
`
appointment
job application
enrolment
pick up / delivery
others:
1. Body Temperature:
2. In the last 14 days up to present, have you experienced these symptoms?
YES
NO
Sore throat
Cough
Colds
Body Pains
Headache
Fever
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?
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)
4. In the last 14 days, have you travelled in another province, city or country?
Yes
Please specify the place:
No
*
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.
