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Health Declaration Form

This health declaration form asks individuals for personal information and to answer questions about COVID-19 symptoms, travel history, contact with COVID-19 positive individuals, and whether they have been advised to self-quarantine. The form requires a signature to declare that all information provided is true and accurate.

Uploaded by

JANET ILLESES
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
36 views2 pages

Health Declaration Form

This health declaration form asks individuals for personal information and to answer questions about COVID-19 symptoms, travel history, contact with COVID-19 positive individuals, and whether they have been advised to self-quarantine. The form requires a signature to declare that all information provided is true and accurate.

Uploaded by

JANET ILLESES
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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HEALTH DECLARATION FORM

Please fill out this form accurately and truthfully. Your health and the health of others are
important to us.

Personal Information
Name: ___________________________
Date of Birth: ______________________
Address: _________________________
Contact Number: ___________________

Health Questions Have you traveled internationally or to any


area with high COVID-19 cases in the last
Have you experienced any of the following
14 days?
symptoms in the last 14 days? (Please
check all that apply) • Yes
• No
• Fever (temperature above 100.4°F /
• Not applicable
38°C)
• Cough Have you been advised to self-quarantine or
• Shortness of breath or difficulty isolate by a healthcare provider or public
breathing health official?
• Sore throat
• Yes
• Loss of taste or smell
• Fatigue • No
• Muscle or body aches • Not applicable
• Headache
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
Have you been in contact with someone
who has tested positive for COVID-19 in the
last 14 days?

• Yes
• No
• Not sure
Declaration
I hereby declare that the information provided above is true and accurate to the best of my
knowledge. I understand the importance of disclosing this information for the safety and well-
being of others.
Signature: ________________________
Date: ____________________________

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