Covid-19 Testing covid-19 testHealth Declaration Please provide the following information for us to better assist you. Full Name Age Gender MaleFemale Contact Number Email Address Have you been recently tested for COVID-19? YesNo Do you have any travel history in the past 14 days? YesNo Did you come in close contact or staying in the same close environment with someone who is a confirmed COVID-19 case? YesNo Did you come in close contact with a Probable or Suspected person with COVID-19? YesNo Have you experienced the following symptoms recently like Fever? YesNo Diarrhea, Nausea, or Vomiting YesNo Shortness of breath or other respiratory symptoms YesNo Other Symptoms Headache YesNo Joint Pain or Muscle Pain YesNo Flu-like symptoms such as: Chills or repeated shaking with chills YesNo Body Aches YesNo Sore Throat YesNo Runny Nose or Sneezing YesNo Cough and Colds YesNo New loss of smell and/or taste YesNo Eye Discharge YesNo Skin rash or discoloration of toes/fingers YesNo Loss of speech or movement YesNo I agree that the information provided in this document is true and correct to the best of my knowledge and understand that any dishonest answers may have serious legal and public health implications under RA 11332. I declare that all information disclosed above is TRUE and CORRECT. Input this code:
