HTML Preview Health Declaration Form COVID19 page number 1.
Health Declaration Form
________ (month) ____ (day) _________ (year)
Name
ID/Passport
No.
Contact
No.:
Permanent/temporary
address in Shanghai
Departed from Hubei Province (□ Yes □ No)
If yes, indicate the date of departure.
□ For people from Wuhan:
□ For people from other cities of Hubei:
□ Train No.
□ Flight No.
□ Coach No. and Plate No.
□ Private Car Plate No.
Stopped along the way (□ Yes □ No)
If yes, indicate the stops.
□ For people from Wuhan:
□ For people from other cities of Hubei:
□ For people from places other than Hubei:
Names of
people traveling
together and
their contact
numbers
Body temperature
My current health conditions:
□ cough □ expectoration □ runny nose □ sore throat □ chest pain/tightness
other symptom(s)
□ none of the above symptoms
I undertake that the information provided above is true and accurate, or I
shall be responsible for all consequences and legal liabilities arising therefrom.
Date: