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    Health Declaration (Triage) Form: (A) Covid-19 (B) Mers Cov and (C) Ebola Virus Disease (Evd)

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    Nakul Singh ParkwayIndia
    This health declaration form is used to screen patients for COVID-19, MERS, and Ebola virus diseases. It asks whether the patient has symptoms like fever, cough or breathing difficulties. It also asks about potential exposures, including recent travel to affected countries, contact with confirmed cases, or living/working in high risk environments. By identifying symptoms and risks, the form helps determine if the patient requires isolation or referral for further testing and management of infectious diseases.

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    © All Rights Reserved
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    Health Declaration (Triage) Form: (A) Covid-19 (B) Mers Cov and (C) Ebola Virus Disease (Evd)

    Uploaded by

    Nakul Singh ParkwayIndia
    72 views1 page
    This health declaration form is used to screen patients for COVID-19, MERS, and Ebola virus diseases. It asks whether the patient has symptoms like fever, cough or breathing difficulties. It also asks about potential exposures, including recent travel to affected countries, contact with confirmed cases, or living/working in high risk environments. By identifying symptoms and risks, the form helps determine if the patient requires isolation or referral for further testing and management of infectious diseases.

    Original Description:

    Health Declaration form for Singapore visa

    Original Title

    SOD_PHSPL_PICHealthDeclareTriageForm

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    This health declaration form is used to screen patients for COVID-19, MERS, and Ebola virus diseases. It asks whether the patient has symptoms like fever, cough or breathing difficulties. It also asks about potential exposures, including recent travel to affected countries, contact with confirmed cases, or living/working in high risk environments. By identifying symptoms and risks, the form helps determine if the patient requires isolation or referral for further testing and management of infectious diseases.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    72 views1 page

    Health Declaration (Triage) Form: (A) Covid-19 (B) Mers Cov and (C) Ebola Virus Disease (Evd)

    Uploaded by

    Nakul Singh ParkwayIndia
    This health declaration form is used to screen patients for COVID-19, MERS, and Ebola virus diseases. It asks whether the patient has symptoms like fever, cough or breathing difficulties. It also asks about potential exposures, including recent travel to affected countries, contact with confirmed cases, or living/working in high risk environments. By identifying symptoms and risks, the form helps determine if the patient requires isolation or referral for further testing and management of infectious diseases.

    Copyright:

    © All Rights Reserved
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    of 1

    Parkway Hospitals Singapore Pte Ltd

    HEALTH DECLARATION (TRIAGE) FORM

    □ GEH □ MEH □ MNH □ PEH □ Others: _______________

    Name: ____________________________________ NRIC /PP No:__________________

    (A) COVID-19; (B) MERS CoV; and (C) Ebola Virus Disease (EVD)
    1 Do you have any of the following?
    a Fever □ Yes □ No
    b Cough or sore throat, running nose or breathing difficulty □ Yes □ No
    c Anosmia (partial or complete loss of the sense of smell) □ Yes □ No
    d Diarrhea or vomiting or bleeding □ Yes □ No
    (A) COVID-19; 1a and/or 1b and/or 1c AND one or more of the followings:
    2 Travelled or residence abroad (i.e to any country outside Singapore) in the last 14 days? □ Yes □ No
    If “Yes”, please specify country and city: ____________________________
    Last date in reported country: _________________

    3 Been in close contact with a case of COVID-19 infection in the last 14 days? □ Yes □ No
    4 Stayed in a foreign worker dormitory in the last 14 days? □ Yes □ No
    5 Worked in occupations or environments with higher risk of exposure to COVID-19 cases? □ Yes □ No
    6 Have prolong fever (≥37.50C) and respiratory symptoms of 4 days or more, and not recovering? □ Yes □ No
    (B) MERS CoV; 1a and/or 1b AND one or more of the following exposures:
    7 Been in contact with camels in the last 14 days? □ Yes □ No
    8 Been in contact with a person who is a confirmed case of MERS-CoV in the last 14 days? □ Yes □ No
    9 Been in any of the following MERS-CoV reported countries* in the last 14 days? □ Yes □ No
    *Middle East countries - Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates and Yemen

    If “Yes”, please specify country and city: ____________________________


    Last date in reported country: _________________
    10 Been in a healthcare facility in the Middle East countries in the last 14 days? □ Yes □ No
    (C) EVD; 1a and/or 1d AND one or more of the following exposures:
    11 Been in areas with reported Ebola Virus Disease (EVD) activity in the last 21 days? □ Yes □ No
    **North Kivu and Ituri Province in the Democratic Republic of Congo (DRC)
    **Refer to WHO’s website at https://www.who.int/ebola/en/ for updated affected areas or countries

    If “Yes”, please specify country and city: ____________________________


    Last date in reported country: _________________
    12 Been in contact with a person who is a confirmed or suspected case of EVD in the last 21 days? □ Yes □ No
    Under the Infectious Disease Act, it is an offence to provide any false information

    Signature of Patient/Next-of-kin: _____________________ Name of Next-of-kin: ____________________

    Name & Signature of Triage Nurse/Staff: ________________________________ Date/Time: __________

    PIC-006-R27-05/20

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