DELEGATE ANGEL SALAZAR JR.
MEMORIAL SCHOOL
HEALTH DECLARATION FORM
Name:Carl Mathew O Madrid
Grade & Section:-VI-Providence
Address:Badiang, San jose, Antique
Contact No. :09650787878
Please check if applicable:
1. Do you currently experience the following symptoms?
YES NO YES NO
1. Fever 7. Runny nose ✔️
2.Dry cough 8. Tiredness ✔️
3.Body weakness 9. Sore Throat ✔️
4. Headache 10. Diarrhea ✔️
5.Loose Bowel Movement 11. Shortness of Breath
6. Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Places visited within the past (2) weeks: _________________________________________
Pupil’s Signature: __________________
Parent/Guardian’s Name and Signature: __________________
Noted by: ______________________________ Verified by: JOCEIL FORNIER
Class Adviser Clinic Teacher
DELEGATE ANGEL SALAZAR JR. MEMORIAL SCHOOL
HEALTH DECLARATION FORM
Name:_____________________________________________________________________
Grade & Section:__________________________________________________________
Address:____________________________________________________________________
Contact No.:____________________________________ Date:______________________
Please check if applicable:
1. Do you currently experience the following symptoms?
YES NO YES NO
1. Fever 7. Runny nose
2.Dry cough 8. Tiredness
3.Body weakness 9. Sore Throat
4. Headache 10. Diarrhea
5.Loose Bowel Movement 11. Shortness of Breath
6. Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Places visited within the past (2) weeks: _________________________________________
Pupil’s Signature: __________________
Parent/Guardian’s Name and Signature: __________________
Noted by: ______________________________ Verified by: JOCEIL FORNIER
Class Adviser Clinic Teacher
DELEGATE ANGEL SALAZAR JR. MEMORIAL SCHOOL
HEALTH DECLARATION FORM
Name:_____________________________________________________________________
Grade & Section:__________________________________________________________
Address:____________________________________________________________________
Contact No.:____________________________________ Date:______________________
Please check if applicable:
1. Do you currently experience the following symptoms?
YES NO YES NO
1. Fever 7. Runny nose
2.Dry cough 8. Tiredness
3.Body weakness 9. Sore Throat
4. Headache 10. Diarrhea
5.Loose Bowel Movement 11. Shortness of Breath
6. Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Places visited within the past (2) weeks: _________________________________________
Pupil’s Signature: __________________
Parent/Guardian’s Name and Signature: __________________
Noted by: ______________________________ Verified by: JOCEIL FORNIER
Class Adviser Clinic Teacher
DELEGATE ANGEL SALAZAR JR. MEMORIAL SCHOOL
HEALTH DECLARATION FORM
Name:_____________________________________________________________________
Grade & Section:__________________________________________________________
Address:____________________________________________________________________
Contact No.:____________________________________ Date:______________________
Please check if applicable:
1. Do you currently experience the following symptoms?
YES NO YES NO
1. Fever 7. Runny nose
2.Dry cough 8. Tiredness
3.Body weakness 9. Sore Throat
4. Headache 10. Diarrhea
5.Loose Bowel Movement 11. Shortness of Breath
6. Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Places visited within the past (2) weeks: _________________________________________
Pupil’s Signature: __________________
Parent/Guardian’s Name and Signature: __________________
Noted by: ______________________________ Verified by: JOCEIL FORNIER
Class Adviser Clinic Teacher
