Patient Screening Form

INTRODUCTION

Makati Medical Center ensures the safety of its patients, employees, visitors and the community by identifying high-risk patients and medical staff managing them accordingly.

In compliance with RA 11332 Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act, it is essential that you provide truthful information about your health condition and possible exposure. The collected data indicated herein is for the purpose of contact tracing to control COVID-19 transmission. The records will be retained in Makati Medical Center and will be destroyed after 30 days from the date of accomplishment, following the National Archives of the Philippines Protocol and Joint Memorandum 20-04 Series of 2020 DTI and DOLE Supplemental Guidelines on Workplace Prevention and Control of COVID-19.

Please fill-out this form at least 24 hours before your scheduled appointment. After you fill-out the form, you will receive an email confirmation detailing your next steps with a PDF copy of the Patient Screening Form. Please print or save the PDF copy and show the copy during your visit.

Validity: This screening form will be valid for five (5) days. Any symptom which may develop or any unprotected exposure within this coverage period for the Patient will automatically invalidate this initial screening session. The Patient should accomplish a new screening form.

Reminders:

NO Patient Screening Report NO Entry
NO Mask NO Entry
NO Face Shield NO Entry (Face shield should cover the whole face, visor types are not allowed)
Allow time for thermal scanning and validation of Patient Screening Report
Observe social distancing at all times
Come Approximately 20 minutes before your procedure
Only one (1) companion is allowed per patient (with his/her own companion Screening Report)
NO Companion Screening Report NO Entry

PATIENT SCREENING QUESTIONNAIRE

Do you have any of the following symptoms within the past 14 days? Yes No
- Respiratory Symptoms Cough Colds Throat Pain Shortness of Breath
- Status of Respiratory Symptoms Worsening Stable/Improving
- Influenza-like Symptoms Headache Body aches or muscle pains Diarrhea with or without Vomiting Weakness Lack of smell or taste
- Fever 38 degrees Celsius or higher Yes No
Did you have any unprotected close contact with a COVID-19 case? Yes No ***Unprotected close contact – being within approximately six (6) feet or two (2) meters of a person with COVID-19 for approximately five (5) minutes or longer and not wearing a face mask.
- Were you tested for COVID-19? Yes No
  - Have you completed 14 days quarantine? Yes No
Have you been hospitalized for COVID-19 or pneumonia for the past month? Yes No
- Have you completed 14 days quarantine? Yes No
- Do you have subsequent NEGATIVE RT-PCR result? Yes No
Have you been tested for COVID-19? Yes No
- Have you had RT-PCR (Swab Test)? Yes No
  - If YES, enter date of swab test?
  - If YES, result? Positive Negative
    - Have you completed 14 days quarantine? Yes No
    - Do you have subsequent RT-PCR Negative result? Yes No
- Have you had Rapid Antibody Test for COVID-19? Yes No
  - If YES, result? Positive either IgG/IgM Negative both IgG/IgM
    - Have you had RT-PCR Test (Swab Test)? Yes No
      - Have you completed the 14 days quarantine? Yes No

COMPANION SCREENING QUESTIONNAIRE

Do you have any of the following symptoms within the past 14 days? Yes No
- Respiratory Symptoms Cough Colds Throat Pain Shortness of Breath
- Status of Respiratory Symptoms Worsening Stable/Improving
- Influenza-like Symptoms Headache Body aches or muscle pains Diarrhea with or without Vomiting Weakness Lack of smell or taste
- Fever 38 degrees Celsius or higher Yes No
Did you have any unprotected close contact with a COVID-19 case? Yes No ***Unprotected close contact – being within approximately six (6) feet or two (2) meters of a person with COVID-19 for approximately five (5) minutes or longer and not wearing a face mask.
- Were you tested for COVID-19? Yes No
  - Have you completed 14 days quarantine? Yes No
Have you been hospitalized for COVID-19 or pneumonia for the past month? Yes No
- Have you completed 14 days quarantine? Yes No
- Do you have subsequent NEGATIVE RT-PCR result? Yes No
Have you been tested for COVID-19? Yes No
- Have you had RT-PCR (Swab Test)? Yes No
  - If YES, enter date of swab test?
  - If YES, result? Positive Negative
    - Have you completed 14 days quarantine? Yes No
    - Do you have subsequent RT-PCR Negative result? Yes No
- Have you had Rapid Antibody Test for COVID-19? Yes No
  - If YES, result? Positive either IgG/IgM Negative both IgG/IgM
    - Have you had RT-PCR Test (Swab Test)? Yes No
      - Have you completed the 14 days quarantine? Yes No

Need assistance? Please call MakatiMed On-Call at 8888-8999 or email us at [email protected]

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