NLAH WEB

Date
Name		Age Sex
Address		Department

PRESENCE OF THE FOLLOWINGGGG

YES/NO

Fever (If YES, what is Temperature?

Cough (Productive/Non-Prodcutive cough)

Shortness of Breath

Colds

Sore Throat

Runny Nose

Nasal congestion

Muscle pains

Headache

Difficulty of Breathing

Diarrhea

Loss of sense of Smell

Loss of sense of Taste

If identified with the presence of the above, since when?

VITAL SIGNS:

BP:

RR:

PR:

Temp:

O2 Sat:

Name of Nurse

TRAVEL HISTORY within the last 14 days

Specify the place/s you've been the past few days
Location	Dates


If with recent travel abroad, specify the location and date of travel abroad.
Location	Dates

Recent travel in the Philippines
NCR:
Date:
Others:
Date:
Others:
Date:

HISTORY OF EXPOSURE within the last 14 days
	YES/NO
Have you undergone COVID-19 testing?
If YES, when
Result :
Have you been in close contact with a confirmed or suspected case/s of COVID-19?
If YES, when
Who?
Have you been in hospital health care facility in our country with confirmed case facility in our country with confirmed or suspected case/s of COVID-19?
Have you been in close contact with a person/relative/friend who works in a hospital/health care facility or is currently living with you?
If YES, specify the hospital/health care facility where the person/relative/friend works:
Have you been in close contact with relative or friend who have been to a country or place with confirmed cases of COVID-19
If YES, specify which country and date of close contact with relative or friend.

I hereby authorize NLAH, 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 protected by RA10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful Information.