Philippine Airport Diagnostic Laboratory System

Patient Profile

Passport No:

Airport Barcode:

Last Name:

First Name:

Middle Name:

Gender/Sex:

Birthdate:

Age:

Nationality:

Civil Status:

Permanent Address

House No./Lot/Bldg:

Province:

Municipality:

Barangay:

Region:

Home Phone Number:

Cellpone Number:

Email Address:

Emergency Contact

Name:

Address:

Contact Number:

Employement Information

I am a frontliner:

I am health worker:

Occupation:

Employer Name:

Work Industry:

Country of Deployment:

Travel History

When were you last time in the Philippines:

Port (Country) of Exit:

Port (City) of Exit:

Airline/Sea Vessel:

Flight No.:

Date of Departure:

Date of Arrival:

Arrival Airport:

OFW:

Purpose of Travel:

Exposure History

History of Exposure to known COVID-19 Case 14 days before the onset of signs and symptoms:

Clinical Information

Fever:

Cough:

Sore Throat:

Colds:

Short/Difficulty of breathing:

Other signs/symptoms,specify:

Quarantine Facility: