BK Health Declaration

Email address * : *This is a required field.

Name(Last Name, First Name, M.I) * : *This is a required field.

Division * : *This is a required field.

Department * : *This is a required field.

I hereby authorize Bell-Kenz Pharma, Inc. to collect and process the data indicated herein for contact tracing affecting control of the COVID-19 transmission. I understand that my personal information is protected by RA 10173 or the Data Privacy act of 2012. Hence, the form is discarded after 30 days from the date of accomplishment following the National Archives of the Philippines

Accept and agree
Disagree

*Please declare which of the following symptoms you are experiencing or have experienced in the last few days? (Ipaalam alin sa mga sumusunod na sintomas ang kasalukuyang nararanasan o naranasan sa nagdaang mga araw?) *This is a required field.

37.5 and above body Temperature (37.5 o mahigit pa na temperatura ng katawan)

Cough (ubo)

Headache (sakit ng ulo)

Shortness of Breath (hirap o kapos sa paghinga)

Sore Throat (pananakit ng lalamunan)

Loss of Taste (pagkawala ng panlasa)

Loss of Smell (pagkawala ng pang-amoy)

Colds (sipon)

Body Malaise (pananakit ng katawan)

Joint Pains (pananakit ng kasu-kasuan)

Muscle Pains (pananakit ng kalamnan)

None of the Above (wala sa anumang nabanggit)

Others :

How many symptoms you are experiencing or have experienced in the last 5 days? (Ilang sintomas ang kasalukuyang nararanasan o naranasan sa nagdaang limang araw?)

When did you start feeling these symptoms? (Kailan nagsimulang makaramdam ng mga sintomas?)Please indicate the date and time. (Mangyaring ideklara ang petsa at oras.)

Have you been travelling in other locations/ Cities/Province outside of your current home address for the past seven (7) days? (Ikaw ba ay naglakbay sa ibang lugar / lungsod / lalawigan bukod sa kasalukuyang tinitirahan sa nagdaang pitong araw? * *This is a required field.
Yes
No

If Yes, please provide the specific location. (Kung Oo, mangyaring ibigay ang tukoy na lokasyon)

Where were you in the last 24 hours? (Nasaan ka sa nagdaang 24 oras?) * *This is a required field.

Kindly enumerate the person/s you came in close contact with within 1 meter and for more than 5 minutes. (Mangyaring isulat ang pangalan ng mga taong iyong nakasalamuha na may isang(1) metrong distansiya lamang o nakaharap ng mahigit sa limang(5) minuto.) * *This is a required field.

Have you had face-to-face contact with a probable COVID-19 case within one (1) meter and for more than 5 minutes for the past 14 days? (Ikaw ba ay may nakasalamuha na maari o kumpirmadong pasyente na may COVID-19 na may isang (1) metro distansya lamang o nakaharap o nakausap ng mahigit sa 5 minuto sa nakalipas na 14 na araw?) * *This is a required field.
Yes
No

Have you provided direct care for a patient with probable or confirmed COVID-19 case without using proper personal protective equipment (PPE) for the past 14 days? (Ikaw ba ay nag-alaga ng maari o kumpirmadong pasyente na may COVID-19 nang hindi nakasuot ng tamang personal protective equipment (PPE) sa nakalipas na 14 na araw?) * *This is a required field.
Yes
No

Have you worked with or stayed in close proximity with a confirmed, suspected, or probable case of COVID 19? (Ikaw ba ay may naka-trabaho, nakasama o nanatili sa isang lugar na maari o may kumpirmadong pasyente ng COVID-19?) * *This is a required field.
Yes
No
Not Aware

Have you had your Covid vaccination? Pls tick all that applies: (Ikaw ba ay nabakunahan na? Ilagay kung ito ay 1st dose, fully vaccinated at may booster shot?) *This is a required field.

1st shot

2nd shot

Booster shot

Family Member
Do you have a family member living with you or living within your compound who is experiencing or has experienced COVID-19 like symptoms? (Mayroon bang miyembro ng pamilya o kasama sa bahay ang nakararanas o nakaranas ng mga sintomas na nabanggit?) *This is a required field. 37.5 above body temperature Headache Cough Colds Sore Throat Loss of Taste Loss of Smell Body Malaise Joint Pains Muscle Pains Shortness of Breath None Others
Kindly enumerate the relationship and age of your family member/s who is experiencing or has experienced COVID-19 like symptoms.(Mangyaring isulat ang relasyon sa miyembro ng pamilya at ang kanilang edad na nakakaranas o nakaranas sa mga sintomas na inyong nabanggit) *This is a required field.
Have they had face-to-face contact with a probable COVID-19 case within one (1) meter and for more than 5 minutes for the past 14 days? (Sila ba ay may nakasalamuha na maari o kumpirmadong pasyente na may COVID-19 na may isang (1) metro distansya lamang o nakaharap o nakausap ng mahigit sa 5 minuto sa nakalipas na 14 na araw?) *This is a required field. Yes No
Have they provided direct care for a patient with probable or confirmed COVID-19 case without using proper personal protective equipment (PPE) for the past 14 days? (Sila ba ay nag-alaga ng maari o kumpirmadong pasyente na may COVID-19 nang hindi nakasuot ng tamang personal protective equipment (PPE) sa nakalipas na 14 na araw?) *This is a required field. Yes No
Have they worked with or stayed in close proximity with a confirmed, suspect, or probable case of COVID 19? (Sila ba ay may naka-trabaho, nakasama o nanatili sa isang lugar na maari o may kumpirmadong pasyente ng COVID-19?) *This is a required field. Yes No Not Aware

In case of emergency, please contact your COVID-19 Compliance Officer:
SANDRA CELZO - 0917-630-89-67 In case of emergency, please contact your COVID-19 Compliance Officer:
GERVY VITAN - 0917-651-86-62 In case of emergency, please contact your COVID-19 Compliance Officer:
JONATHAN LINO - 0917-844-67-87 In case of emergency, please contact your COVID-19 Compliance Officer:
DENNIS TORIBIO - 0917-856-82-03

In case of emergency, please contact your COVID-19 Compliance Officer:
SANDRA CELZO - 0917-630-89-67 / CAMILLE LAPUZ - 0917-704-10-99 In case of emergency, please contact your COVID-19 Compliance Officer:
GERVY VITAN - 0917-651-86-62 / JONATHAN LINO - 0917-844-67-87 In case of emergency, please contact your COVID-19 Compliance Officer:
GERVY VITAN - 0917-651-86-62 / JONATHAN LINO - 0917-844-67-87 In case of emergency, please contact your COVID-19 Compliance Officer:
DENNIS TORIBIO - 0917-856-82-03 / POPE ABAD - 0917-702-64-42

Saving Response