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Health Checklist Form
David's Salon SM City Dasmarinas
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* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Temperature
*
Your answer
Gender
*
Female
Male
Age
*
Your answer
Residence
*
Your answer
Contact Number
*
Your answer
Are you experiencing : body pains, headache, fever for the past few days, fatigue, cough, sneezing, diarrhea, runny or stuffy nose, shortness of breath, ? If yes, please specify.
*
Body pains
Headache
Fever
Sneezing/ Runny or Stuffy Nose
Shortness of breath
NONE OF THE ABOVE
Required
Have you had any contact with anyone who has fever, cough, colds, and sore throat in the past 2 weeks?
*
Yes
No
Have you recently been in contact with anyone who has tested positive for COVID-19?
*
Yes
No
By submitting this form, you allow David's Salon SM City Dasmarinas branch to collect and process the data indicated herein for the purpose of effecting control of the Covid-19 infection.
Your personal information is protected by RA 10173, Data Privacy Act of 2012, and required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.
A copy of your responses will be emailed to the address you provided.
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