MEDICAL DECLARATION FORM

THIS IS IMPORTANT DOCUMENT, YOUR INFORMATION IS VITAL TO ALLOW HEALTH AUTHORITIES CONTACT YOU TO PREVENT COMMUNICABLE DISEASES
Warning: Declaring false information is a violation of Vietnamese law and may be subject to criminal handling

Travel information (*)

Contact address in Vietnam

Phone number you will use in Vietnam (Is Roaming number or Vietnam number)

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
Fever (*)
Cough (*)
Difficulty of breathing (*)
Sore throat (*)
Symptoms Yes No
Vomiting (*)
Diarrhea (*)
Skin haemorrhage (*)
Rash (*)
History of exposure: During the last 14 days, did you (*)
Yes No
Visit any poultry farm / living animal market / slaughter house / contact to animal(*)
Care for a sick person of communicables diseases(*)