Health Declaration Form

Health Declaration Form

  Use this template

  Share this form

  Having Issue?

COVID-19 Health Declaration Form
* Required

Disclaimer

Parents / Guardians to are reminded that providing false information is an offence under the Malaysian Government Infection Disease Act. The clinic will be obliged to report such false information

Have you travel to any other country (outside of Malaysia) within the last 14 days? *

Yes

No

If yes, which city (country), Date of return?

Have you attended or had contact with anyone who attended mass gathering? *

Yes

No

If yes, which and what gathering?

Have you been in close contact with a person with confirmed Covid-19? *

Yes

No

* For e.g.) attended business meeting/discussion, front line staff in hospitality & tourism, travelled with Covid-19 positive person

Do you have any of the following symptoms:

Fever

Cough

Flu (Runny Nose)

Sore throat

Diarrhea / Vomiting / Nausea

Sudden loss of Smell / Taste

Name of Patient *

IC / Passport No. *

Contact No. *

Ready to get started?

See more templates

Never submit passwords in the form.
Report Abuse | Terms of Service
Powered by

Applify Forms Services
See how you can create your own form for free!

Form published & in use

What do you want to do?

Back to Designer

Custom Prompt

Please wait while we're checking your order availability

Share / Send for participation

How do you want to share your form?

QR Code:

Try to scan with your smartphone!

URL / Link:

Click to Open Email Client:

Share on WhatsApp:

Share on Facebook:

<iframe id="myframeApplify" src="" frameborder="0" allowtransparency="true" frameborder="0" style="overflow:hidden;height:100%;width:100%;min-height: 450px;" height="100%" width="100%" allowfullscreen></iframe>

Note: Copy above code to your website

Embed is not available in your current subscription.
Ready to unlock more of Applify's powerful features?
🚀 Upgrade your plan now and experience the full potential!
Click to explore our plans: View Plans

© Copyright 2024 Applify Digital Sdn Bhd 202401001145 (1546996-D)
All Rights Reserved