Health Assessment Form

The survey will take approximately 4 minutes to complete.

1Introduction
2Demographics
3Other Information
4Screening Form
5Vaccination Details
6Reminders

Introduction

Safety of patients, visitors, employees and medical staff, stakeholders, and the community is one of main thrusts of Manila Doctors Hospital. The implementation of this health assessment tool, together with continuous reminder to strictly adhere to minimum public health standards, is our way of ensuring that the goal will be achieved. We also observe and protect the data privacy of our visitors in accordance with the Data Privacy Law R.A. 10173.

All information will be strictly treated with confidentiality.

Demographics

Gender

Other Information

Screening Form

Please select the symptom/s you experienced within or for the past 14 days.

If "NO" symptoms please select "None"

Did you have contact with an individual with COVID-19 for the last 14 days?

Close encounter with COVID-confirmed individual/s within 1 meter for the past 72 hours?

Travel or reside in area with local COVID-19 transmission for the past 14 days?

Vaccination Details

Have you been fully vaccinated for COVID-19 (Two doses w/ or w/o booster)

Reminders

Have you been fully vaccinated for COVID-19 (Two doses w/ or w/o booster)

  • Please don't forget to bring proof of your vaccination
  • Always follow MDH:
    • Mask and face shield must be worn at all times within the hospital premises.
    • Distance of at least 1 meter should be observed
    • Hand hygiene is a must
  • Allow time for thermal scanning and validation of Health Screening form you accomplished.
  • Only 1 companion who is negative in health screening is allowed per patient.
  • Health Assessment is valid for 24 hours only.

Terms & Conditions

By completing this questionnaire, I give permission to provide my personal information to Manila Doctors Hospital in relation to the processing of COVID-19 health screening and contact tracing purposes during this pandemic.