Daily Health Declaration Form

Valid for one day only

Instructions: Fill this out in the morning every day. You must provide TRUTHFUL information about your health condition and possible exposure. Any falsification is PUNISHABLE with one to six months IMPRISONMENT and a 20,000 to 50,000 FINE (Republic Act 11332).

Instruction: Please tick the appropriate response if YES or NO

EXPOSURE WITHIN THE PAST 14 DAYS (from date of visit)

SIGNS AND SYMPTOMS (during the date of visit)