HEALTH STATEMENT FORM

Name (required)

Email Address (required)

Contact No. (required)

Body Temperature (required)

Are you experiencing:

1. Fever for the past few days?
   YesNo

2. Sore Throat?
   YesNo

3. Body pains?
   YesNo

4. Headache?
   YesNo

Cough?
YesNo

Cold?
YesNo

Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?
YesNo

Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks?
YesNo

Have you travelled outside of the Philippinesin the last 14 days?
YesNo

Have you travelled outside Metro Manila the last 14 days?
YesNo

Member's Signature