HEALTH CHECKLIST FORM

Temperature Reading

Sex Male Female

Age

Residence

Contact No.

Nature of Visit (Please check one)

If official, fill in company details below: Company Name

Company Address Please put a checkmark on your response to each question:

Are you experiencing the following symptoms

Sore throat

Cough (Ubo)

Colds (Sipon)

Body Pain

Headache

Fever for the past few days

Have you worked together or stayed in the same close environment of a confirmed Covid-19 case?

Have you had any contact with anyone with fever cough, colds, and sore throat in the past two weeks?

Have you travelled outside of the Philippines in the last 14 days?

Temperature reading
I hereby authorize LIPA QUALITY CONTROL CENTER INC. to collect and process the data indicated herein for the purpose of effecting control of the covid-19 infection. I Understand that my personal information is protected by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

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