Kompletong PangalanDahilan ng Pagpasok:Teacher/EmployeeLearnerParentVisitorOras ng Pagpasok:Oras-120102030405060708091011Minuto-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMStreet Address *CityState/ProvinceDateMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Kasarian: *LalakiBabaeNumero ng Telepono: *Bibisitahin sa Loob ng Paaralan *Baitang at Pangkat: *Kung magulang isulat ang baitang at pangkat ng bata.1. Are you experiencing any of the following symptoms? (Nakakaranas ka ba ngayon ng mga sumusunod na sintomas?FEVER ( LAGNAT) *MeronWalaCOUGH (UBO) *MeronWalaCOLDS (SIPON) *MeronWalaSORE THROAT (SAKIT NG LALAMUNAN) *MeronWalaDIFFICULTY OF BREATHING (HIRAP SA PAGHINGA) *MeronWalaBODY PAIN ( SAKIT NG KATAWAN) *MeronWalaLOST OF TASTE AND SMELL ( PAGKAWALA NG PANG-AMOY O PANLASA) *MeronWala2. Did you have a travel history outside Cavite in the last 14 days? ( Ikaw ba ay nagbiyahe sa labas ng Cavite sa nakalipas na 14 na araw?) *OoHindi3. Indicate your present condition and medication/s. (Kung meron, ilagay ang iyong kasalukuyang kondisyon at iniinom na gamot.) Huwag kalilimutan na maghugas ng kamay at maglapay na alkohol. Kunin ang inyong temperatura at ilagay sa ibaba. Temperature *Submit Share this:FacebookLinkedInTwitterEmailLike this:Like Loading...
