Edelyn Quimio —

Good condition

Age: 22
Gender: Female
Address: Makiling Calamba City Laguna

SELF DECLARATION FORM

Are you experiencing:
Most common symptoms:

❌ Fever
❌ Dry cough
❌ Sore throat
❌ Shortness of Breath
❌ Loss of smell

Some patients may also have:

❌ Fatigue
❌ Aches and Pains
❌ Runny Nose
❌ Diarrhea
❌ Headache

✅❎

❎ Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?

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

❎ Have you travelled outside the Philippines in the last 14 days?

❎ Have you travelled to any area in NCR aside from your home?

OH HEY, FOR BEST VIEWING, YOU'LL NEED TO TURN YOUR PHONE