Visitor and Employee Health Checklist

CLINIC HEALTH SCREENING

Employee & Visitor Health Checklist

Please complete this health declaration form before entry. Your honest responses help us maintain a safe, clean, and professional clinic environment.

Health Screening for a Safer Environment

APEX Health Screening Form

Health Declaration Form

Fill in all required information and answer each item truthfully.

Visit ID

Health Checklist *

Visitor

Employee

Date Visit *

Phone

Temperature

Symptoms & Exposure Screening

Please respond to the following questions truthfully by selecting Yes or No.

Are you experiencing: (nakakaranas ka ba ng:)

Fever

Yes

Fever for the past few days (Lagnat sa nakalipas na mga araw)

Sore Throat

Yes

(Pananakit ng lalamunan/ masakit lumunok)

Headache

Yes

(Pananakit ng ulo)

Nausea

Yes

(Pagkahilo or pagkaduwal)

Body Pains

Yes

(Pananakit ng katawan)

Vomiting

Yes

(Pagsusuka)

Fatigue

Yes

(Pagkapagod)

Diarrhea

Yes

(Pagdudumi o pagtatae)

Cough

Yes

(Pag-ubo)

Abdominal Pain

Yes

(Sakit sa tiyan)

Colds

Yes

(Sipon)

Loss of Taste

Yes

(Pagkawala ng panlasa)

Shortness of Breath

Yes

(lgsi ng paghinga)

Loss of Smell

Yes

(Pagkawala ng pang-amoy)

Difficulty Breathing

Yes

(Hirap sa paghinga)

Sore Eyes

Yes

(Pamamaga at pagsakit ng mga mata)

Rashes

Yes

(Pantal sa balat)

Expose to Covid

Yes

Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao na kumpirmadong may COVID-19/ may impeksyon ng coronavirus?)

Exposure to Fever/Cough/Colds

Yes

Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas ng dalawang (2) lingo?).

Recent Travel History

Yes

Have you travelled outside of Davao Region in the last 14 days? (Ikaw ba ay nagbyahe sa labas ng Davao Region sa nakalipas na 14 na araw?).

Exposure Risk

Yes

Have you travelled to any area with known local transmission? (Ikaw ba ay nagpunta sa mga lugar na may local transmission? Specify (Sabihin kung saan):

Submit Health Form