Symptoms Assessment for the GESM Community

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COVID-19 Symptoms Assessment

Personal Information

Name

Birthday

Contact Number

Are you fully vaccinated against Covid-19?

Fully vaccinated means 2 weeks after your second dose in a 2-dose series, such as Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s

YES

NO

Have you had your RT-PCR test done?

If yes, please indicate information:

Date done

Date of resultt

Upload test result here

Select File

Are you a Close Contact Person to a Confirmed Covid-19 Case?

YES

NO

Are you currently experiencing any of the following symptoms?

Fever or chills

YES

NO

Cough

Colds

YES

NO

YES

NO

Shortness or difficulty of breathing

YES

NO

Tiredness

YES

NO

Muscle or

body aches

YES

NO

Headache

YES

NO

Loss of taste or smell

YES

NO

Sore throat

YES

NO

Diarrhea

YES

NO

TEMPERATURE READING :

List of Close Contact Persons

Close contact means:

face to face contact with or without facemask within 1 meter for more than 15 minutes e.g., talking, meeting
direct physical contact e.g., shake hands, cheek greetings
direct care for confirmed or suspect for Covid-19 without using approved PPE
persons you ate with (indoor, regardless of distance), (outdoor within or less than 1 meter distance)

1.Name

1.Nature of Exposure

1Active Contact Number

2.Name

2.Nature of Exposure

2. Active Contact Number

3.Name

3.Nature of Exposure

3.Active Contact Number

4.Name

4.Nature of Exposure

4. Active Contact Number

5.Name

5.Nature of Exposure

5.Active Contact Number

6.Name

6.Nature of Exposure

6. Active Contact Number

7.Name

7.Nature of Exposure

7.Active Contact Number

8.Name

8.Nature of Exposure

8. Active Contact Number

9.Name

9.Nature of Exposure

9.Active Contact Number

10.Name

10.Nature of Exposure

10. Active Contact Number

Thank you for completing this Covid-19 Symptoms Assessment.

Who to contact:

Email nursejmarquez@gesm.org

mhombrobueno@gesm.org

+639171249158

More Information

What to do if you are sick:

Kindly accomplish the web-based questionnaire for assessment