Health Condition Declaration Form

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Health Condition Declaration Form

Health Condition Declaration Form

Pursuant to Republic Act 11332, you are required to provide truthful information about your health condition and possible exposure.

Dear Patients,

I would like to ensure both our safety during and after your consult/procedure in my clinic. Let us make this happen by checking the appropriate box.

Do you and/or your child have fever?YesNo

Do you and/or your child have sore throat?YesNo

Are you and/or your child experiencing cough or colds?YesNo

Do you and/or your child have shortness of breath or difficulty of breathing?YesNo

Are you and/or your child experiencing headaches?YesNo

Do you and/or your child have muscle pain?YesNo

Do you and/or your child have diarrhea?YesNo

Do you and/or your child consult a medical doctor for the above mentioned sign and symptoms?YesNo

Do you and/or your child have a history of travel within 14 days?YesNo

If yes, where?

If yes, when

Do you or anyone in the household have any of the above mentioned signs and symptoms or pending Covid-19 test results?YesNo

Have you and/or your child travelled to or live in an local areas outside the Philippines where there are reported cases of Covid-19YesNo

Have you and/or your child been exposed to a person with a suspected/probable/positive case of Covid-19?YesNo

New onset of skin lesion, discoloration of fingers or toesYesNo

Did you travel internationally or domestically for the past two (2) weeks?YesNo

Have you been in contact with someone who has confirmed or suspected to have COVID-19 infection in the past two weeks?YesNo

Does anyone in your household have any of the above mentioned signs and symptoms?YesNo

Do you and/or your child have contact or exposure to someone who travelled in areas with local transmission?YesNo

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Youthplus Medical Group Directory Contacts

Youthplus Medical Center

Youthplus Pharmacy

Dr. Yo Nutri Cafe

Youthplus Skin & Laser Center

Zamora Branch

Marasbaras Branch

Catarman Branch

Ormoc Branch

Our Emails

Health Condition Declaration Form

OUR EMAILS

[email protected]

[email protected]

FOLLOW OUR SOCIAL PROFILE

DESIGNED AND DEVELOPED BY TELMO

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OUR DOCTORS

Youthplus Medical Group Directory Contacts

Youthplus Medical Center

Youthplus Pharmacy

Dr. Yo Nutri Cafe

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