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:
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:
coughexpectoration □ 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:
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