Medical declaration for inland people

( COVID-19 EPIDEMIC PREVENTION )

Warning: Declaring false information is a violation of Vietnamese law and may be subject to criminal handling

Full name (CAPITAL LETTERS) (*)

Passport number / ID card

Year of Birth (*)

Gender (*)

Nationality (*)

Have a health insurance card

Contact address in Vietnam

Province (*)

District (*)

Ward (*)

Address of residence in Vietnam (House number, street, residential group / village / team, ward / commune, district, district, province / city) (*)

Phone (*)

The building where you work

Building (*)

Other (clarify) (*)

The company / department you are working in

The company / department you are working in (*)

Other (clarify) (*)

In the last 21 days, which regions/ countries/ territories have you traveled to (may travel across multiple places) Yes (*) No (*)

Moving in the country

Vehicle (*)

Start (*)

Departure (*)

(*) (*)

End (*)

Destination (*)

(*) (*)

Transportation No. (*)

Seat No. (*)

Start date (*)

End Date (*)

Have you noticed any of the following signs in the last 21 days? (*)

Symptoms	Yes	No
Fever (*)
Cough (*)
Shortness of breath (*)
Pneumonia (*)
Sore throat (*)
Tired (*)

During the past 21 days, you were in contact with (*)

	Yes	No
Sick or suspected person, infected with COVID-19 (*)
People from countries with COVID-19 disease (*)
People with manifestations (fever, cough, shortness of breath, pneumonia) (*)

Which of the following diseases do you currently have? (*)

Name of illness	Yes	No
Chronic liver disease (*)
Chronic blood disease (*)
Chronic lung disease (*)
Chronic kidney disease (*)
Heart-related diseaes (*)
High Blood Pressure (*)
Immunocompromised (*)
Transplant recipients, Mercury bone (*)
Diabetes (*)
Cancer (*)
Pregnant (*)

The data you provide is completely confidential and only serves for the prevention of epidemics, under the management of the Steering Committee for Disease Prevention Covid-19 of Bitexco Joint Stock Company and its attached units. When you press "Submit", you understand and agree with the above statement.