MEDICAL DECLARATION FORM. This is important document, your information is vital to allow health authorities contact you to prevent communicable diseases. Contact information in Viet Nam. If you have any of the followings at present or during the past 14 d

MEDICAL DECLARATION FORM

This is important document, your information is vital to allow health authorities contact you to prevent communicable diseases

▪ Full name (BLOCK LETTERS): ..................................................................................

▪ Date of Birth: ……………………. Gender: …………………. Nationality: ........................

▪ Passport number or other legal document: ..................................................................

Travel information: Plane □ Ship □ Automobile □ Other (clarify): .....................................

Transportation No.:............................................... Seat No.: ………………………………..

Departure date: ……. /…….. /………………….. Immigation date: …….. /………/.................

Place of departure (province/country): ..........................................................................

Place of destination (province/country): .........................................................................

In the past 14 days, have you been to any province/city/territory/country? If yes, where?: ………

Contact information in Viet Nam

▪ Staying address: .......................................................................................................

▪ Tel. /Mob.: ......................................................... Email: ……………………………………

If you have any of the followings at present or during the past 14 days (until the date of entry/exit/transit)?

Symptoms	Yes	No	Symptoms	Yes	No
▪ Fever	[ ]	[ ]	▪ Vomiting	[ ]	[ ]
▪ Cough	[ ]	[ ]	▪ Diarrhea	[ ]	[ ]
▪ Difficulty of breathing	[ ]	[ ]	▪ Rash	[ ]	[ ]
▪ Sore throat	[ ]	[ ]	▪ Skin haemorrhage	[ ]	[ ]

List of vaccines or biologicals used: ……………………………………………………………..

History of exposure: During the last 14 days, did you:

▪ Visit any poultry farm/ living animal market/ slaughter house/ contact to animal	Yes [ ] No [ ]
▪ Care for a sick person of communicables diseases	Yes [ ] No [ ]

The information I have given is true, correct and complete. I understand failure to answer any question may have serious consequences.

Date: Month: Year: 202...

Signature of Passenger/Crew

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GUIDANCE

Passenger uses this part for entry/exit/transit clearance and for protection of your health ▪ Full name (BLOCK LETTERS): ………………………………………………………….. ▪ Province/City/Territory/Country of departure: ……………………………………………

VERIFICATION BY HEALTH QUARANTINE OFFICER Day Month Year 202…

For your own heath and that of the community, if you experience any of the above-mentioned symptoms, please contact heath quarantine units at points entry or the nearest healthcare centre or email to Email: …………………….. or Fax: …………………………………….. Hotline of province/city of point of entry: ... Hotline of the Ministry of Health: ...

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