Oakridge International School Health Declaration Form
Your Name:
*
First Name
Last Name
Date of Visit
-
Month
-
Day
Year
Date
Time of Visit
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Person to Visit
Purpose
Email Address:
*
Email
Mobile Number:
Mobile
Phone Number:
*
-
Area Code
Phone Number
Did you come in close contact with any person suffering from COVID19 in the last 14 days?
Yes
No
Have you ever been admitted to or visited a hospital in the past one month?
Yes
No
Cities in the Philippines you have visited in the past 14 days
Do you have any of the following flu-like symptoms?
Fever
Cough
Breathlessness
Sore throat
Running nose
Muslce Join Pain
Chest Pain
Signature
Clear
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