PRLI Health Declaration Form

Visitor's Name:*
Contact No.:*
Trucking Name:
Plate No.:
Age:*
Gender:*	MALE      FEMALE

Are you experiencing (nakaranas ka na ba ng): *
	YES	NO
Sore throat (pananakit ng lalamunan/masakit lumunok)
Body pains (pananakit ng katawan)
Headache (pananakit ng ulo)
Fever for the past few days (lagnat na nakalipas na mga araw)
Colds (sinisipon)
Cough (colds)

Have you worked together or stayed in the same close environment of a confirmed COVID-19 case) (May nakasama ka ba o nakatrabahong tao na kumpirmadong may COVID-19 / ay impeksyon ng coronavirus) *
YES	NO

Have you had any contact with anyone with fever, cough, colds and sore throat in the past 2 weeks? (Mayroon ka bang nakasama na May lagnat, ubo, sipon, o sakit ng lalamunan sa nakalipas na dalawang (2) linggo?) *
YES	NO

Have you travelled to any area in NCR aside from your home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong bahay?) *
YES	NO

Please specify (sabihin kung saan) *