La Consolacion University General
Hospital
Gov. Padilla Road, Poblacion, Plaridel 3004, Bulacan
Tel. No’s. (044) 795-1236; (044) 795-42
(first name) (middle name) (last name)
NAME: AGE/SEX/CS:
COMPLETE ADD:
COVID-19 PANDEMIC UNDER THE “NEW
HMO:
NORMAL”
RELIGION:
BDAY:
CELL PHONE #
BRAND OF VACCINE:
NO. OF DOSES GIVEN:
DATE OF 1ST DOSE:
DATE OF 2ND DOSE:
VACCINATION FACILITY:
BOOSTER:
DATE OF BOOSTER SHOT:
VACCINATION FACILITY:
COMORBIDITIES: ( ) HYPERTENSION ( ) DIABETES ( )ASTHMA ( ) ALLERGIES
OCCUPATION:
EMPLOYER:
WORK ADDRESS AND CONTACT NO:
HISTORY OF EXPOSURE TO COVID PATIENT:
CONTACT TRACING AND NUMBER: TRAVEL HISTORY:
1. DATE: WHERE:
2.
3.
4.
5.
DAILY HEALTH DECLARATION FORM
In adherence to the Provisions of RA 11332 known as the
“Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern”
Punishable Acts under RA 11332
Section 9 of the law provides for the acts which are prohibited, namely:
(a) Unauthorized disclosure of private and confidential information pertaining to a patient’s medical condition or treatment;
(b) Tampering of records or intentionally providing misinformation [SINADYANG MAG-BIGAY ng MALING IMPORMASYON] ;
(c) Non - operation of the disease surveillance and response systems;
(d) Non-cooperation of persons and entities that should report and/or respond to notifiable Diseases or health events of public concern;
[HINDI PAKIKIISA ng mga tao sa PAG-UULAT ng karamdaman/sakit at mga kaganapan sa personal na kalusugan na maaaring malawakang makaapekto
o makasama sa kalusugan ng maraming tao.] and,
(e) Non - cooperation of the person or entities identified as having the notifiable disease, or affected by the health event of public concern.
DECLARATION / ACKNOWLEDGMENT
I, hereby personally declare, that I have read and understood the provisions stipulated under Section 9 of RA 11332 in the foregoing and state as follows:
That Within the FOURTEEN (14) days prior to the Date of this Health Declaration Form, I HAVE
YES NO
1. Respiratory Symptoms
a. Cough
b. Shortness of breath
c. Colds
d. Throat Pain
e. Other Symptoms (lbm, vomiting, body weakness)
f. Influenza-like symptoms (headache, muscle and joint pains, diarrhea, lack of smell or taste
2. Fever more than 38°C.
3. History of COVID-19 Infection.
4. Household member diagnosed with COVID-19.
5. Travel or Residence in an area reporting local transmission of COVID-19.
6.
7. Contact or exposure to someone with recent travel to an area with local transmission of COVID-19.
I ACKNOWLEDGE and ACCEPT that this Declaration shall be governed by the laws of the Republic of the Philippines. I irrevocably agree that the
competent Philippine Courts shall have jurisdiction to hear and determine any suit, action or proceeding, and to settle any dispute which may arise out of, under, or in
connection with this Declaration and for such purposes hereby irrevocably submit to the jurisdiction of such Courts
_______________________________________________________
(Signature over Printed Name)
Date: ________________
