COVID-19 Health Status Daily Monitoring Last Name * First Name * Middle Initial * Present Address * Area Code * Contact Number * Sex * —MaleFemale Age * Your email address: * Temperature * Have you attended mass gathering, a reunion of relatives/friends, parties within a month prior to this survey? * YesNo Have you been in close contact with a COVID-19 positive patient? * YesNo Have you been in close contact with a COVID-19 PUI/Probable patient? * YesNo Have you been in close contact with a COVID-19 PUM/Suspect patient? * YesNo Do you have a flu-like/respiratory symptoms? * FeverCoughRunny NoseSore ThroatHeadacheShortness of breathChillsGeneral malaise (general discomfort or mild sickness)DiarrheaNONE Do you have pre-existing conditions? * HypertensionAsthmaDiabetesKidney ProblemCancerNONEOther If yes is your answer to the previous question, please specify: Do you take maintenance drugs? * YesNo If yes is your answer to the previous question, please specify: Are you pregnant? * YesNo Are you currently experiencing medical emergency? * YesNo If yes is your answer to the previous question, please specify: Declaration and Data Privacy Consent: The information I have given is true, correct, and complete. I understand that failure to answer any question or giving false answers can be penalized in accordance with the law. I voluntarily and freely consent to the collection and sharing of the above personal information only in relation to CCA Manila & Cravings’ COVID-19 internal protocols in accordance with the Data Privacy Act.