Health Clearance Survey (Weekly)

Name:

Mobile No.

Sex:

Age:

Home Address:

Company Address:

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 purposes):


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

Fever of 38 degrees Celsius or above

Sore throat

Coughs and colds

Headaches

Difficulty in breathing

Stomach pain / diarrhea

Nausea / vomiting

Losing appetite

Loss of taste/Loss of smell


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

Fever of 38 degrees Celsius or above

Sore throat

Coughs and colds

Headaches

Difficulty in breathing

Stomach pain / diarrhea

Nausea / vomiting

Losing appetite

Loss of taste/Loss of smell


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 you or 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?

Yes

No

  If yes, where and when?


9. Did anyone from your household attend a mass gathering/meeting in the last 14 days?

Yes

No

  If yes, where and when?


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

Yes, medical frontliner (doctors, nurses, pharmacists, nutritionists, allied medical professionals, etc.).

Yes, maintenance staff (janitors, electricians, waste disposal staff, drivers, etc.).

Yes, basic services frontliner (cashiers, bank tellers, food delivery staff, fast food staff, etc.).

Yes, government employees (skeletal workforce of the governement, police force, military, etc.).

No, none of us are frontliners.


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

Yes, I am a suspected case (Individuals who show symptoms of influeza-like illness such as fever and dry cough, those with travel history to areas with confirmed local transmission of COVID-19, and people with exposure to a confirmed case).

Yes, I am a probable case (Suspected cases who are waiting COVID-19 test results, who are not yet tested, or whose throat and nasal swabs were examined in an unaccredited testing facility)

Yes, I am a confirmed case (people who tested positive for COVID-19)

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.