COVID - 19 Patient Screening Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Pursuant to Republic Act 11332, you are required to provide truthful information about your health condition and possible exposure.

To help us provide care to our patients in the midst of the COVID-19 pandemic, we are asking all patients to provide the following information prior to making an office appointment. It is essential that this information is accurate and complete. We respect your privacy and this information will be protected.Thank you for your cooperation- Asian Hair Restoration Center and Arambulo Dermatology Center.

In compliance with the Data Privacy Act of 2012, Asian Hair Restoration Center and Arambulo Dermatology Center ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

Name *

Date Today *

YYYY

Date of birth *

YYYY

Age *

Sex *

Female

Male

Email *

Contact Number *

PART I. Signs and Symptoms

Have you experienced any of the following in the past 14 days? ( Please check all that applies)

Cough

Chills/Fever (T° 38°C)

Colds

Fatigue/ Body Weakness / Muscle Pain

Shortness of Breath or Difficulty of Breathing

Sore Throat

Decreased sense of smell &/or taste

Other:

PART II. TRAVEL AND EXPOSURE HISTORY

Do you have close contact (live in the same household, work in the same office, providedirect patient care, or travel together) with someone who is a probable or confirmed COVID case? *

YES

If yes, close contact/s

Have you or any member of your household or close contacts travelled within or outside the country in the past two (2) weeks? *

YES

If yes, place and date of travel

PART III. Agreement

By signing this form with my initials, I confirm that: I have been informed that Asian Hair Restoration Center and Arambulo Dermatology Center is undertaking these measures to ensure that the well-being and protection of everyone, myself included, is prioritized. The information I have provided are TRUE and CORRECT and I am aware that any untruthful statements I make may have serious consequences on public health and safety for which I may be held liable under the law. (Sign your Initials below) *

Are all of the above statements are true, accurate and complete? *

I pledge that all of the above statements are true, accurate and complete

Required

Other Comments:

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms