Full Name *Buong Pangalan

Birth date *Petsa ng Kapanganakan

Email Address *

Phone Number *

I have had a fever in the past 2 weeks *YesNoAko ay nilagnat ng nakalipas na 2 linggo

I have had a cough in the past 2 weeks *YesNoAko ay inubo ng nakalipas na 2 linggo

I have experienced unexplained shortness of breath in the past 2 weeks *YesNoAko ay nakaranas ng hindi maipaliwanag na kakapusan ng hininga ng nakalipas na 2 linggo

I had flu or flu-like symptoms in the past 2 weeks *YesNoAko ay nakaranas ng trangkaso o sintomas ng trangkaso nitong nagdaang 2 linggo

I had diarrhea in the past 2 weeks *YesNoAko ay nakaranas ng diarrhea nitong nagdaang 2 linggo

I have traveled to and from a known location of a COVID-19 outbreak *YesNoAko ay nakapunta o nagmula sa lugar na nagkaroon ng COVID-19 outbreak

I have been in contact with someone traveling from a known location of a COVID-19 outbreak *YesNoAko ay may contact sa taong nagpunta sa lugar na nagkaroon ng COVID-19 outbreak

I have been in close contact with someone receiving treatment for COVID-19 *YesNoAko ay may close contact sa taong nagpapagamot dahil sa COVID-19

I work in a hospital or care center that has treated a case of COVID-19 *YesNoAko ay nagtratrabaho sa pagamutan o care center na gumagamot sa kaso ng COVID-19

I am elderly or at the risk of having a weakened immune system *YesNoAko ay matanda na o may panganib na magkaroon ng panghihina ng immune system

I experience chronic illness such as high blood pressure, diabetes, heart disease, chronic lung disease or cancer *YesNoAko ay nakakaranas ng malubhang sakit tulad ng high blood pressure, diabetes, heart disease, chronic lung disease or cancer

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I declare under penalty of the laws of the United States of America and the Philippines that the statements above are true and correct.

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