Full Name

Address (City Only)

Mobile Number

Email

Ministry (if any)

Purpose of entering COG

Date of entry to COG

1. In the last 2 weeks, have you experienced:

a. Fever (temperature of 37.5°C and above) YesNo
b. Sore Throat YesNo
c. Body Pains YesNo
d. Headache YesNo
e. Shortness of breath or difficulty in breathing YesNo
f. Runny nose / colds YesNo

2. Are you pregnant or do you have any pre-existing health condition (e.g. diabetes, hypertension, asthma, etc.)? YesNo
If yes, specify:

3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past two (2) weeks? YesNo

4. In the last two (2) weeks, have you worked together or stayed in the same close environment of a confirmed or suspected COVID-19 case? YesNo

5. Does anyone who stays in your house work as a medical or non-medical frontliner (e.g hospital staff, barangay health workers, police or military personnel, grocery worker, bank employee, food delivery crew, etc.)? YesNo

6. In the last two (2) weeks, what activities have you done that required you to go out of your house? Specify what and where:

7. In the last two (2) weeks, has anyone visited or stayed in your house other than your immediate family members? YesNo
If yes, specify who and why:

8. In the last two (2) weeks, have you visited or done any of the following:
Hospital / ClinicLeisure (e.g. cinema, concert, travelling, etc.)Social Gatherings (e.g. birthday parties, weddings, reunions, etc.)Contact Sports (e.g. basketball, volleyball, etc.)

9. In the last two (2) weeks, was there an increase in the number of confirmed COVID-19 cases in your barangay? YesNo
Please give details: