HEALTH DECLARATION FORM
I hereby declare that the information I will provide is complete and accurate. I fully understand that any false information can put the staff attending to me at a high risk of contracting COVID-19 disease.

I fully agree to follow all the instructions regarding precautionary steps advised by the designer I will visit (E* Chi'mes Pharmaceutical Inc.). I give my consent to ECPI to collect and process data indicated herein for the purpose of effecting control of the COVID-19 infection.
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Email *
Temperature *
Complete Name *
Complete Address *
Mobile/Phone Number *
Date of visit *
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Time of visit
Time
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In the last 14 days, have you been in close contact or exposed to any person suspected of COVIDS-19? *
Required
Were you confined in a hospital/health care facility during the past 14 days? *
Required
Have you been diagnosed to have pneumonia in the past 14 days? *
Required
Do you have any household member/s or close contact/s who are currently having fever, cough, or any respiratory problems? *
Required
In the last 14 days, have you been in contact with a COVID-19 confirmed person? *
Required
Are you experiencing dry cough in the last 14 days? *
Required
Are you experiencing fever >37.5 C in the last 14 days? *
Required
Are you experiencing colds/runny nose in the last 14 days? *
Required
Are you experiencing sore throat in the last 14 days? *
Required
Are you experiencing shortness of breath in the last 14 days? *
Required
Are you experiencing headache in the last 14 days? *
Required
Are you experiencing body aches in the last 14 days? *
Required
Are you experiencing body weakness in the last 14 days? *
Required
Are you experiencing sneezing in the last 14 days? *
Required
Are you experiencing nausea/vomiting in the last 14 days? *
Required
Are you experiencing lost of smell or taste in the last 14 days? *
Required
Are you experiencing exhaustion in the last 14 days? *
Required
Are you experiencing diarrhea in the last 14 days? *
Required
I hereby authorized E* Chi'mes Pharmaceutical Inc., to collect and process the data indicated herein for the purpose of contact tracing effecting control of the COVID-19 transmission. I understand that my personal information is protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 30 days from the date of accomplishment, following the National Archives of the Philippines protocol. *
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