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Supercare Medical Services, Inc. Health Declaration Form: Remarks of Examining Physician

The document is a health declaration form completed by Junexiel Galbizo Jalop on May 30, 2020 for Inter-Orient Maritime Enterprises, Inc. It asks questions about their exposure and symptoms related to COVID-19. Jalop answers that they have not been diagnosed with COVID-19, have not been in contact with anyone who has COVID-19, and have not experienced any symptoms in the last 14 days such as fever, cough or difficulty breathing. They also confirm they have not traveled outside of their home in Metro Manila in the last 27 days.

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JunexielJalop
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458 views1 page

Supercare Medical Services, Inc. Health Declaration Form: Remarks of Examining Physician

The document is a health declaration form completed by Junexiel Galbizo Jalop on May 30, 2020 for Inter-Orient Maritime Enterprises, Inc. It asks questions about their exposure and symptoms related to COVID-19. Jalop answers that they have not been diagnosed with COVID-19, have not been in contact with anyone who has COVID-19, and have not experienced any symptoms in the last 14 days such as fever, cough or difficulty breathing. They also confirm they have not traveled outside of their home in Metro Manila in the last 27 days.

Uploaded by

JunexielJalop
Copyright
© Public Domain
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SUPERCARE MEDICAL SERVICES, INC.

HEALTH DECLARATION FORM


Name: JUNEXIEL GALBIZO JALOP Date: 30-May-2020
Agency: INTER-ORIENT MARITIME ENTERPRISES, INC.

As part of our precautionary measures to prevent the spread of COVID - 19, please answer truthfully the questions below.
Giving of false or erroneous information or answer is a crime punishable under existing law

HISTORY OF EXPOSURE YES NO SYMPTOMS YES NO


1. Have you been declared as a SUSPECT or PROBABLE Do you currently have or had the following
case of COVID-19 before, during or after the Enhanced symptoms for the past 14 days? (Mayroon ka ba
Quarantine Period (Ikaw ba ay naitalaga na SUSPECT o X ngayon o nagkaroon ng mga sumusunod na
PROBABLE na kaso ng COVID-19 bago, habang o sintomas sa nakaraang 14 na araw?)
pagkatapos ng Enhanced Quarantine Period)?* If yes, specify date:
Fever (Lagnat) X
2. Have you been diagnosed as a CONFIRMED case of
COVID-19 and recovered from it (Ikaw ba ay nasuri na Cough (Ubo) X
X
CONFIRMED na kaso ng COVID-19 at gumaling dito) ?* Colds (Sipon) X
3. Have you had close contact with anyone declared as Difficulty in breathing (Hirap sa paghinga)
SUSPECT, PROBABLE or CONFIRMED case of COVID19 X
X
for the past 27 days? (Ikaw ba ay may nakasalamuha na Sore throat (Namamagang lalamunan) X
SUSPECT, PROBABLE o CONFIRMED na kaso ng Fatigue (Pagkapagod)
COVID-19 sa nakaraang 27 na araw)? X
If yes, specify date: Sputum production (Produksyon ng plema) X
4. Have you had close contact with any person with flu-like Shortness of breath (Pagkahingal)
symptoms for the past 27 days?? (Ikaw ba ay may X
X
nakasalamuha na may mga sintomas ng trankaso sa Headache (Sakit ng ulo) X
nakaraang 27 na araw)? Chills (Panginginig) X
If yes, specify date:
Nausea or vomiting (Pagduduwal or pagsusuka) X
5. Have you had any activities which you think might have
exposed you unknowingly to COVID19 like travel abroad, X Hemoptysis (Pag ubo na may bahid ng dugo) X
going to social gatherings, going to hospitals etc in the last
Diarrhea (Pagtatae) X
27 days (Ikaw ba ay may mga gawain na sa iyong palagay
ay naglantad sa iyo sa COVID19 ng lingid sa iyong Nasal Congestion (Pagbabara ng ilong) X
kaalaman katulad ng pagbiyahe sa ibang bansa, pagpunta
Sore Eyes (Pamumula ng mata) X
sa mga pagtitipon o pagpunta sa ospital etc. ng nakaraang
27 na araw) ? X I hereby declare that above answers are true and correct.
If yes, specify date:
6. Have you travelled to any areas in NCR or Metro Manila X I understand that this will be validated later.
aside from your home in the last 27 days? (Ikaw ba ay X
nagpunta sa iba pang parte ng NCR o Metro Manila bukod X If found that I have lied and have given false information, I understand
sa iyong bahay sa nakaraang 27 na araw) ? that I could be recommended for Disqualification from employment and is,
If yes, specify date: subject to punishment based on existing Philippine laws

*please provide medical certificate

I hereby authorize SuperCare Medical Services, 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 Remarks of Examining Physician:
Protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as
One Act, to provide truthful information.

JUNEXIEL GALBIZO JALOP/30-May-2020 Name/Sign of MD:

Signature over printed name / date


As of 05.20.2020

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