Name

Address

Date of Visit

Purpose

1. Have you travelled to any area in NCR aside from your home in the last 14 days?

Yes

No

2. List the places you've been to yesterday (For contact tracing puposes)

3. Did you personally experience any of the following within the past 14 days (2 weeks)? Choose all that apply.

Fever of 38 degrees Celcius or above

Sore throat

Coughs and colds

Headaches

Difficult in breathing

Stomach pain / diarrhea

Nausea / vomiting

Losing appetite

None

4. Did any of your family members or people you are living currently experience any of the following within the past 14 days (2 weeks)? Choose all that apply.

Fever of 38 degrees Celcius or above

Sore throat

Coughs and colds

Headaches

Difficult in breathing

Stomach pain / diarrhea

Nausea / vomiting

Losing appetite

None

5. How many in your household are currently experiencing the said symptoms?

Only Me

1-2 people

3-4 people

5 above

Not applicable

6. For those who are experiencing symptoms, did any of the people you are living with currently have any history of travel abroad?

Yes

No

Not applicable

7. For those who are experiencing symptoms, did any of the people you are living with currently had any contact with a COVID-19 positive patient?

Yes

No

Not applicable

8. Have you attended a mass gathering/meeting in the last 14 days? If Yes, where and when? If No, write n/a.

9. Did anyone from your household attend a mass gathering/meeting in the last 14 days? If Yes, where and when? If No, write n/a

10. Are any of you (and people you are living with currenty) frontliners during this COVID-19 pandemic?. Choose all that apply.

Yes, medical frontliner

Yes, maintenance stafft

Yes, basic services frontliner

Yes, goverment services

No, none of us are frontliners

11. Were you (or any of the people you are living with currently) formally diagnosed in a health situation?

Yes, I am suspected case.

Yes, I am probable case.

Yes, I am a confirmed case.

No

12. What medical condition, that is not COVID-19 related, are you experiencing? Please specify. (e.g diabetes, hypertension). Write n/a if this is not applicable to your situation.

13. What health problems, that is not COVID-19 related, are you experiencing during this ECQ? Please specify. (e.g sprain, mental health-related conditions). Write n/a if this is not applicable to your situation.