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

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

SUBMIT

Please do not fill in this field.