Philippine Airport Diagnostic Laboratory System

Patient Profile


Philippine Residence

Employment Information

Travel History

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Exposure History

Clinical Information

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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: