Philippine Relief and Development Services Inc.

Serving the People in Jesus name!

Covid-19 Survey

Thank You for Participation. For Covid Related Concerns: DOH COVID-19 emergency hotlines 02-894-COVID (02-894-26843) and 1555

Full Name

Mobile Phone Number

Address Line 1

Address Line 2

E-Mail

Gender

Male

Female

Do you currently have fever reaching 38°C?

Yes

Do you have a sore throat?

Yes

Do you have a cough

Yes

Do you have a cold?

Yes

Do you find it difficult to breathe

Yes

Have you been suffering from stomach pain or Diarrhea ?

Yes

Have you been feeling nauseous and/or vomiting?

Yes

Did you travel abroad in the past 14 days?

Yes

Have you had interaction with confirmed CO-VID-19 patients?

Yes