Health declaration form
All fields are required.
NB: It is an offence under the Infectious Disease Act to provide false declaration.
Have you been diagnosed with COVID-19 in the last 14 days?
Yes
No
Do you have any of the following symptoms:
No
Fever
Cough
Shortness of breath
Runny nose
Sore throat
Have you been overseas in the last 10 days?
Yes
No
If yes, please indicate all the countries that you have travelled to in the last 10 days.
Have you been issued with HRW or SHN?
Yes
No
Did you have contact with any case of COVID-19 in the last 7 days?
Yes
No
Did you visit any hospital in the last 7 days?
Yes
No
Do you work or live in a communal setting eg. dormitory, nursing home?
Yes
No
Name
NRIC No.
Contact No.
Acknowledgement:
I acknowledge that I’ll turn up for my appointment unaccompanied. Only one accompanying adult will be allowed for minors.
...
Declaration:
I hereby declare that I have answered the above questions truthfully.
Send
